Provider Demographics
NPI:1407038169
Name:PRIMECARE PL
Entity Type:Organization
Organization Name:PRIMECARE PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-827-0078
Mailing Address - Street 1:2720 US HIGHWAY 1 S # B
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6301
Mailing Address - Country:US
Mailing Address - Phone:904-827-0078
Mailing Address - Fax:904-827-0140
Practice Address - Street 1:2720 US HIGHWAY 1 S # B
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6301
Practice Address - Country:US
Practice Address - Phone:904-827-0078
Practice Address - Fax:904-827-0140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58662207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270845101Medicaid
FL270845104Medicaid
FL270845106Medicaid
FL270845102Medicaid
FL97705OtherBCBS
FL270845105Medicaid
FL270845102Medicaid