Provider Demographics
NPI:1598179954
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:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-955-9949
Mailing Address - Street 1:6255 INKSTER RD STE 207
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:734-427-6570
Mailing Address - Fax:734-427-6140
Practice Address - Street 1:6255 INKSTER RD STE 207
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:734-427-6570
Practice Address - Fax:734-427-6140
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME HEALTHCARE SERVICES - GARDEN CITY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-13
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI8082Medicare PIN