Provider Demographics
NPI:1639391808
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:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-458-4490
Mailing Address - Street 1:6245 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-4001
Mailing Address - Country:US
Mailing Address - Phone:734-458-4490
Mailing Address - Fax:734-458-4723
Practice Address - Street 1:8012 MIDDLEBELT ROAD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185
Practice Address - Country:US
Practice Address - Phone:734-425-1225
Practice Address - Fax:734-261-0284
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME GARDEN CITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX IDENTIFICATION NUMBER