Provider Demographics
NPI:1407098643
Name:PRIME MEDICAL GROUP PCG1
Entity Type:Organization
Organization Name:PRIME MEDICAL GROUP PCG1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE 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 1:515 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-1405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1645 ROSTRAVER RD
Practice Address - Street 2:SUITE 202
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036822L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGOtherHIGHMARK BLUE SHIELD
PA0006836970001Medicaid
PAPENDINGOtherHIGHMARK BLUE SHIELD
PA031306K55Medicare PIN