Basic Information
| Provider Information | |||||||||
| NPI: | 1841200110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMEDICAL HEALTHCARE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 HIGHWAY 105 EXT STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286074291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282647311 | ||||||||
| FaxNumber: | 8282647907 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 HIGHWAY 105 EXT STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286074291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282647311 | ||||||||
| FaxNumber: | 8282647907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | PLACENTRA | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8282647311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 960068 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 891033X | 05 | NC | MEDICAID | 89014XX | 05 | NC | MEDICAID |