Provider Demographics
NPI:1609421841
Name:PRIMARY CARE GROUP LLC
Entity Type:Organization
Organization Name:PRIMARY CARE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMENICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FANTINI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:908-505-5141
Mailing Address - Street 1:2 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-3226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-3226
Practice Address - Country:US
Practice Address - Phone:908-505-5141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty