Provider Demographics
NPI:1063512010
Name:PRIME GARDEN CITY MEDICAL GROUP
Entity Type:Organization
Organization Name:PRIME GARDEN CITY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
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 1:6245 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-4001
Mailing Address - Country:US
Mailing Address - Phone:734-458-4490
Mailing Address - Fax:734-458-4723
Practice Address - Street 1:6245 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-4001
Practice Address - Country:US
Practice Address - Phone:734-458-4490
Practice Address - Fax:734-458-4723
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME HEALTHCARE SERVICES--GARDEN CITY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX IDENTIFICATION NUMBER
MI=========OtherTAX IDENTIFICATION NUMBER
MIP82133OtherBLUE CARE NETWORK (GROUP)