Basic Information
Provider Information | |||||||||
NPI: | 1750324521 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIME CARE MEDICAL CENTER PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 PRIME CARE DR | ||||||||
Address2: |   | ||||||||
City: | SELMER | ||||||||
State: | TN | ||||||||
PostalCode: | 383751864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316457932 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 PRIME CARE DR | ||||||||
Address2: |   | ||||||||
City: | SELMER | ||||||||
State: | TN | ||||||||
PostalCode: | 383751864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316457932 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 08/05/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KING | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | DARRELL | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7316457932 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3717104 | 05 | TN |   | MEDICAID | CG1877 | 01 |   | RAILROAD MEDICARE | OTHER | 3717101 | 05 | TN |   | MEDICAID | 3717102 | 05 | TN |   | MEDICAID |