Provider Demographics
NPI:1023002029
Name:PRIMA PRIMARY MEDICAL ASSOCIATION, INC
Entity Type:Organization
Organization Name:PRIMA PRIMARY MEDICAL ASSOCIATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:COVNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-202-0011
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 355
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-202-0011
Mailing Address - Fax:858-202-0055
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 355
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-202-0011
Practice Address - Fax:858-202-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1984005592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11865Medicare ID - Type Unspecified