Provider Demographics
NPI:1558540161
Name:PRIME MD LLC
Entity Type:Organization
Organization Name:PRIME MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZAN
Authorized Official - Middle Name:KHALIL
Authorized Official - Last Name:ABDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-535-8500
Mailing Address - Street 1:5005 SIGNAL BELL LN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-2606
Mailing Address - Country:US
Mailing Address - Phone:443-535-8500
Mailing Address - Fax:410-531-1446
Practice Address - Street 1:5005 SIGNAL BELL LN
Practice Address - Street 2:SUITE 202
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-2606
Practice Address - Country:US
Practice Address - Phone:443-535-8500
Practice Address - Fax:410-531-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050878207R00000X
MDD50870320800000X
MDD046855320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCF698OtherBSDC
DCF698OtherBSDC
MD198MMedicare PIN
MDMD198MMedicare PIN
DCF698OtherBSDC
MDG66525Medicare UPIN