Provider Demographics
NPI:1568074078
Name:PRIMETIME MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PRIMETIME MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PELSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DARIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-512-0522
Mailing Address - Street 1:1975 E SUNRISE BLVD STE 501
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1410
Mailing Address - Country:US
Mailing Address - Phone:954-512-0522
Mailing Address - Fax:
Practice Address - Street 1:1975 E SUNRISE BLVD STE 501
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1410
Practice Address - Country:US
Practice Address - Phone:954-512-0522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD620670872821OtherDRIVERS LICENSE