Provider Demographics
NPI:1235171570
Name:PRIME MEDICAL GROUP
Entity Type:Organization
Organization Name:PRIME MEDICAL GROUP
Other - Org Name:PRIME MEDICAL LONG
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SETHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-929-2640
Mailing Address - Street 1:PO BOX 18619
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-0619
Mailing Address - Country:US
Mailing Address - Phone:724-929-2640
Mailing Address - Fax:
Practice Address - Street 1:1645 ROSTRAVER RD
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-9655
Practice Address - Country:US
Practice Address - Phone:724-929-2260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-12
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008635790002Medicaid
PA1007726550009Medicaid
PA000031306OtherHIGHMARK PROV NUMBER
PA0010652420006Medicaid
PA717558OtherHIGHMARK
PA769210OtherHIGHMARK
PA0014690470004Medicaid
PA31238OtherHIGHMARK
PA0006836970001Medicaid
PA1936740OtherHIGHMARK
PA692541OtherHIGHMARK
PA692646OtherHIGHMARK
PA0019214160001Medicaid
PA717558OtherHIGHMARK
PA064901K55Medicare PIN
PA769210Medicare PIN
PA074417K55Medicare PIN
PA692541OtherHIGHMARK
PA031238K55Medicare PIN
PA478104K55Medicare PIN
PA031306K55Medicare PIN
PA400994K555Medicare PIN