Provider Demographics
NPI:1578743704
Name:PRIME HEALTHCARE,LLC
Entity Type:Organization
Organization Name:PRIME HEALTHCARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BAI
Authorized Official - Middle Name:
Authorized Official - Last Name:KANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-805-2500
Mailing Address - Street 1:3233 SUPERIOR LN
Mailing Address - Street 2:B21
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1920
Mailing Address - Country:US
Mailing Address - Phone:301-805-2500
Mailing Address - Fax:301-805-0114
Practice Address - Street 1:3233 SUPERIOR LN
Practice Address - Street 2:B21
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1920
Practice Address - Country:US
Practice Address - Phone:301-805-2500
Practice Address - Fax:301-805-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD106NMedicare PIN
MDG01360Medicare PIN