Provider Demographics
NPI:1548802218
Name:PRIME GARDEN CITY MEDICAL GROUP
Entity Type:Organization
Organization Name:PRIME GARDEN CITY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MANZUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-434-5464
Mailing Address - Street 1:6255 INKSTER RD STE 302
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2538
Mailing Address - Country:US
Mailing Address - Phone:734-458-3330
Mailing Address - Fax:
Practice Address - Street 1:6255 INKSTER RD STE 302
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2538
Practice Address - Country:US
Practice Address - Phone:734-458-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME GARDEN CITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty