Provider Demographics
NPI:1568635282
Name:PRIME CARE PHYSICIAN PC
Entity Type:Organization
Organization Name:PRIME CARE PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GIRIJA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIPUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-583-0960
Mailing Address - Street 1:121 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1857
Mailing Address - Country:US
Mailing Address - Phone:248-583-0960
Mailing Address - Fax:248-583-0961
Practice Address - Street 1:121 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1857
Practice Address - Country:US
Practice Address - Phone:248-583-0960
Practice Address - Fax:248-583-0961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066341208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4593972Medicaid
MI4593972Medicaid