Provider Demographics
NPI:1104163013
Name:PRIME GARDEN CITY MEDICAL GROUP
Entity type:Organization
Organization Name:PRIME GARDEN CITY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-458-4490
Mailing Address - Street 1:6221 N TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3222
Mailing Address - Country:US
Mailing Address - Phone:313-561-2200
Mailing Address - Fax:313-561-2211
Practice Address - Street 1:6221 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3222
Practice Address - Country:US
Practice Address - Phone:313-561-2200
Practice Address - Fax:313-561-2211
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME GARDEN CITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-11
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q26334Medicare PIN