Basic Information
| Provider Information | |||||||||
| NPI: | 1700131604 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME CARE PHYSICIANS, PLLC | ||||||||
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| OtherOrganizationName: | NORTHEAST ADVANCED IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 ATRIUM DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122051441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184352740 | ||||||||
| FaxNumber: | 5186494025 | ||||||||
| Practice Location | |||||||||
| Address1: | 279 TROY RD | ||||||||
| Address2: | ROUTE 4 | ||||||||
| City: | RENSSELAER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121449499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188806300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHALEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 5184352704 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02616571 | 05 | NY | MEDICAID | 1011152 | 05 | VT | MEDICAID |