Provider Demographics
NPI:1083776728
Name:DARTMOUTH PRIMARY MEDICINE, LLC
Entity Type:Organization
Organization Name:DARTMOUTH PRIMARY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-971-9737
Mailing Address - Street 1:651 ORCHARD ST
Mailing Address - Street 2:SUITE 202 A
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02744-1008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 ORCHARD ST
Practice Address - Street 2:SUITE 202 A
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02744-1008
Practice Address - Country:US
Practice Address - Phone:508-994-5300
Practice Address - Fax:508-994-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220351261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076216AMedicaid
MAI09877Medicare UPIN
MAM21890Medicare PIN