Provider Demographics
NPI:1184823114
Name:PRIMARY CRITICAL CARE MEDICAL GROUP
Entity Type:Organization
Organization Name:PRIMARY CRITICAL CARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:T
Authorized Official - Last Name:GIPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-509-2222
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91603-0998
Mailing Address - Country:US
Mailing Address - Phone:818-509-2222
Mailing Address - Fax:818-509-2229
Practice Address - Street 1:501 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4809
Practice Address - Country:US
Practice Address - Phone:818-843-5111
Practice Address - Fax:818-843-0641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42382208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty