Provider Demographics
NPI:1427208537
Name:PRIME GARDEN CITY MEDICAL GROUP
Entity Type:Organization
Organization Name:PRIME GARDEN CITY MEDICAL GROUP
Other - Org Name:CENTER FOR SPORTS AND FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-458-4490
Mailing Address - Street 1:35600 CENTRAL CITY PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2046
Mailing Address - Country:US
Mailing Address - Phone:734-261-3778
Mailing Address - Fax:734-524-0981
Practice Address - Street 1:35600 CENTRAL CITY PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2046
Practice Address - Country:US
Practice Address - Phone:734-261-3778
Practice Address - Fax:734-524-0981
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME GARDEN CITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-25
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty