Provider Demographics
NPI:1316286032
Name:PRIME PEDIATRICS, LLC
Entity type:Organization
Organization Name:PRIME PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARNOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-977-2440
Mailing Address - Street 1:845 QUINCE ORCHARD BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1676
Mailing Address - Country:US
Mailing Address - Phone:301-977-2440
Mailing Address - Fax:301-977-4752
Practice Address - Street 1:845 QUINCE ORCHARD BLVD STE B
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1676
Practice Address - Country:US
Practice Address - Phone:301-977-2440
Practice Address - Fax:301-977-4752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00583752080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0400041 00Medicaid