Provider Demographics
NPI:1275752750
Name:JANICE PRIME CARE MEDICAL PC
Entity Type:Organization
Organization Name:JANICE PRIME CARE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT JANICE PRIME CARE MEDICAL
Authorized Official - Prefix:
Authorized Official - First Name:MEENAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-708-7008
Mailing Address - Street 1:14 KRISTI DRIVE
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753
Mailing Address - Country:US
Mailing Address - Phone:516-708-7008
Mailing Address - Fax:134-746-4085
Practice Address - Street 1:1530 BEDFORD AVE FL 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4117
Practice Address - Country:US
Practice Address - Phone:718-400-6951
Practice Address - Fax:347-789-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03313595Medicaid
NY03313595Medicaid