Basic Information
| Provider Information | |||||||||
| NPI: | 1184819302 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME HEALTHCARE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 08/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | ALBANO | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8602630253 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208000000X | 54316 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004201480 | 05 | CT | MEDICAID | 008058707 | 05 | CT | MEDICAID | 004185147 | 05 | CT | MEDICAID |