Basic Information
| Provider Information | |||||||||
| NPI: | 1750769584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRI- CARE EXPRESS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064731704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032392727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 79 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032392727 | ||||||||
| FaxNumber: | 2036432081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2015 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | WASSERMAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2032392727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 36223 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1487680625 | 01 | CT | NPI | OTHER |