Provider Demographics
NPI:1407933286
Name:PRIME CARE MEDICAL GROUP P.C.
Entity Type:Organization
Organization Name:PRIME CARE MEDICAL GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:VIDYAPRIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGANATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-753-8477
Mailing Address - Street 1:2457 E MAIN ST STE 1E
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-2684
Mailing Address - Country:US
Mailing Address - Phone:203-753-8477
Mailing Address - Fax:
Practice Address - Street 1:2457 E MAIN ST STE 1E
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2684
Practice Address - Country:US
Practice Address - Phone:203-753-8477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCG3286OtherRAIL ROAD MEDICARE
CTCG3286OtherRAIL ROAD MEDICARE