Basic Information
| Provider Information | |||||||||
| NPI: | 1154377489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMA MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 HAMILTON LANDING | ||||||||
| Address2: | #160 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 CIVIC CENTER DR | ||||||||
| Address2: | #200B | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949034171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154923333 | ||||||||
| FaxNumber: | 4154923425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | HABRIS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4154923333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G73451 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.