Basic Information
| Provider Information | |||||||||
| NPI: | 1992925986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME CARE PHYSICIANS, P.L.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GLENS FALLS ASSOCIATES IN CARDIOLOGY | ||||||||
| 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: | 156 QUAKER RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128041718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187931083 | ||||||||
| FaxNumber: | 5187930953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| 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 | 207R00000X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0011X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 2083P0901X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 363AM0700X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 54964 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207RC0000X | 54964 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 02616571 | 05 | NY | MEDICAID |