Provider Demographics
NPI:1417932294
Name:PRIMECARE OF SOUTHEASTERN OHIO, INC.
Entity Type:Organization
Organization Name:PRIMECARE OF SOUTHEASTERN OHIO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-454-4651
Mailing Address - Street 1:860 BETHESDA DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1800
Mailing Address - Country:US
Mailing Address - Phone:740-454-4651
Mailing Address - Fax:740-454-4653
Practice Address - Street 1:751 FOREST AVE STE 402
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2878
Practice Address - Country:US
Practice Address - Phone:740-454-4651
Practice Address - Fax:740-454-4653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0989499Medicaid
CA1586OtherMEDICARE RAILROAD
OH0989499Medicaid