Provider Demographics
NPI:1023198728
Name:PRIMEDOC PARK RIDGE PA
Entity Type:Organization
Organization Name:PRIMEDOC PARK RIDGE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-237-3378
Mailing Address - Street 1:PO BOX 60262
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0262
Mailing Address - Country:US
Mailing Address - Phone:843-237-3378
Mailing Address - Fax:843-237-5073
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-5272
Practice Address - Country:US
Practice Address - Phone:843-237-3378
Practice Address - Fax:843-237-5073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905717Medicaid
NC018NXOtherBLUE CROSS BLUE SHIELD
NC018NXOtherBLUE CROSS BLUE SHIELD