Provider Demographics
NPI:1326117276
Name:PRIMECARE PEDIATRICS
Entity Type:Organization
Organization Name:PRIMECARE PEDIATRICS
Other - Org Name:DR JAY GOPAL MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-532-2147
Mailing Address - Street 1:5820 YORK RD
Mailing Address - Street 2:STE 23
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5820 YORK RD
Practice Address - Street 2:STE 23
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3610
Practice Address - Country:US
Practice Address - Phone:410-532-2147
Practice Address - Fax:410-323-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31052332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133154OtherOTHER ID NUMBER-COMMERCIAL NUMBER