Provider Demographics
NPI:1154947695
Name:PRIME 5 MEDICAL GROUP INC
Entity type:Organization
Organization Name:PRIME 5 MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PEJMAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SHAMEKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-279-9328
Mailing Address - Street 1:PO BOX 6033
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-1033
Mailing Address - Country:US
Mailing Address - Phone:310-788-0044
Mailing Address - Fax:310-277-3659
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC4602133OtherBUSINESS LICENSE