Provider Demographics
NPI: | 1184819302 |
---|---|
Name: | PRIME HEALTHCARE, PC |
Entity Type: | Organization |
Organization Name: | PRIME HEALTHCARE, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | SUSAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ALBANO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 860-263-0253 |
Mailing Address - Street 1: | 30 JORDAN LN |
Mailing Address - Street 2: | |
Mailing Address - City: | WETHERSFIELD |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06109-1278 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 860-263-0253 |
Mailing Address - Fax: | 860-263-0262 |
Practice Address - Street 1: | 30 JORDAN LN |
Practice Address - Street 2: | |
Practice Address - City: | WETHERSFIELD |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06109-1278 |
Practice Address - Country: | US |
Practice Address - Phone: | 860-263-0253 |
Practice Address - Fax: | 860-263-0262 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-09-11 |
Last Update Date: | 2015-08-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207R00000X, 207RC0200X, 207RE0101X, 207RG0100X, 207RG0300X, 207RP1001X, 208M00000X, 363A00000X, 363L00000X, 363LA2200X, 363LF0000X | ||
CT | 54316 | 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 004201480 | Medicaid | |
CT | 008058707 | Medicaid | |
CT | 004185147 | Medicaid | |
CT | 004201480 | Medicaid |