Provider Demographics
NPI:1124298443
Name:PRIME HEALTH MEDICAL SERVICES
Entity type:Organization
Organization Name:PRIME HEALTH MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAILA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMAA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-291-2511
Mailing Address - Street 1:8120 GARNET DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-2141
Mailing Address - Country:US
Mailing Address - Phone:937-291-2511
Mailing Address - Fax:937-291-2523
Practice Address - Street 1:8120 GARNET DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-2141
Practice Address - Country:US
Practice Address - Phone:937-291-2511
Practice Address - Fax:937-291-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-068963207LP2900X
OH1982111N00000X
OH350868963G261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2032982Medicaid
OH6403990001Medicare NSC
OH9358391Medicare PIN