Provider Demographics
NPI:1033505110
Name:PRIME GARDEN CITY MEDICAL GROUP
Entity Type:Organization
Organization Name:PRIME GARDEN CITY MEDICAL GROUP
Other - Org Name:B. NAKHLEH, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:PARSONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-458-4490
Mailing Address - Street 1:4190 24TH AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3882
Mailing Address - Country:US
Mailing Address - Phone:810-216-4000
Mailing Address - Fax:810-216-4001
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-216-4000
Practice Address - Fax:810-216-4001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME GARDEN CITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E93977Medicare UPIN