Basic Information
| Provider Information | |||||||||
| NPI: | 1871713636 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME CARE PHYSICIANS, P.L.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIME CARE PHYSICIANS, P.L.L.C. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 ATRIUM DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122051441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184352704 | ||||||||
| FaxNumber: | 5184582610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1444 WESTERN AVE | ||||||||
| Address2: | SUITE B-1 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122033440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184582611 | ||||||||
| FaxNumber: | 5184891914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHALEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 5184352704 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207R00000X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LA2200X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207Q00000X | 54964 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02616571 | 05 | NY | MEDICAID |