Provider Demographics
NPI:1972615540
Name:PRIMECARE MEDICAL
Entity type:Organization
Organization Name:PRIMECARE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PRUDANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-327-1908
Mailing Address - Street 1:316 COURTLAND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906-2269
Mailing Address - Country:US
Mailing Address - Phone:203-348-3142
Mailing Address - Fax:203-348-3445
Practice Address - Street 1:555 NEWFIELD AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3330
Practice Address - Country:US
Practice Address - Phone:203-327-1908
Practice Address - Fax:203-327-5803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02358Medicare PIN
CI3567Medicare PIN