Provider Demographics
NPI:1093720427
Name:PRIMECARE MEDICAL GROUP
Entity Type:Organization
Organization Name:PRIMECARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:REVELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-932-0996
Mailing Address - Street 1:8521 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-2540
Mailing Address - Country:US
Mailing Address - Phone:813-932-0996
Mailing Address - Fax:813-932-0266
Practice Address - Street 1:8521 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-2540
Practice Address - Country:US
Practice Address - Phone:813-932-0996
Practice Address - Fax:813-932-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35878207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty