Provider Demographics
NPI:1073590105
Name:PRIMARY CARE ASSOCIATES MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:PRIMARY CARE ASSOCIATES MEDICAL GROUP, INC
Other - Org Name:COASTAL ORTHOPAEDICS & SPORTS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-724-1033
Mailing Address - Street 1:3998 VISTA WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4500
Mailing Address - Country:US
Mailing Address - Phone:760-724-5173
Mailing Address - Fax:760-724-5265
Practice Address - Street 1:3998 VISTA WAY
Practice Address - Street 2:SUITE B
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4500
Practice Address - Country:US
Practice Address - Phone:760-724-5173
Practice Address - Fax:760-724-5265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70831207X00000X, 207XS0117X
CAA47884207X00000X
CAA68137207XX0005X
CAE4564213ES0103X
CAPA17120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0089840Medicaid
CAGR0089840Medicaid