Provider Demographics
NPI:1316235880
Name:PERSONALIZED PRIMARY CARE CENTER, LLC
Entity type:Organization
Organization Name:PERSONALIZED PRIMARY CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:F
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-685-7285
Mailing Address - Street 1:2301 E EVESHAM RD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4501
Mailing Address - Country:US
Mailing Address - Phone:856-685-7285
Mailing Address - Fax:856-685-7675
Practice Address - Street 1:2301 E EVESHAM RD
Practice Address - Street 2:SUITE 407
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4501
Practice Address - Country:US
Practice Address - Phone:856-685-7285
Practice Address - Fax:856-685-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F35866Medicare UPIN