Basic Information
| Provider Information | |||||||||
| NPI: | 1679712764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME MEDICAL GROUP PCG1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 ALLEGHENY CTR FL 7 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152125255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123305861 | ||||||||
| FaxNumber: | 4123305844 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 BROOKS LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | CLAIRTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150253749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4124665502 | ||||||||
| FaxNumber: | 4124698948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2009 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | NOEL | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4123305861 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.