Provider Demographics
NPI:1093016651
Name:PRIMARY CARE GROUP LLC
Entity Type:Organization
Organization Name:PRIMARY CARE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:LANE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:901-478-0525
Mailing Address - Street 1:1211 UNION AVE
Mailing Address - Street 2:STE 700
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6638
Mailing Address - Country:US
Mailing Address - Phone:901-516-0546
Mailing Address - Fax:901-516-0528
Practice Address - Street 1:2961 CANADA RD
Practice Address - Street 2:STE 105
Practice Address - City:LAKELAND
Practice Address - State:TN
Practice Address - Zip Code:38002-4893
Practice Address - Country:US
Practice Address - Phone:901-388-0115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDR2914OtherRAILROAD MEDICARE
MS01450214Medicaid
MSDS1812OtherRAILROAD MEDICARE
TN4290151OtherBCBS TN
TN1522556Medicaid
AR194628002Medicaid
MS01450214Medicaid
TNDR2914OtherRAILROAD MEDICARE