Basic Information
| Provider Information | |||||||||
| NPI: | 1124013040 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME CARE PHYSICIANS, P.L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEALTH STREAM MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17 GLENN POND ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | RED HOOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125711824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457586046 | ||||||||
| FaxNumber: | 8457586051 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 GLENN POND ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | RED HOOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125711824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457586046 | ||||||||
| FaxNumber: | 8457586051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAVANNA | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8457586046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02616571 | 05 | NY | MEDICAID |