Provider Demographics
NPI:1659669588
Name:PRIME MEDICAL OF THE FINGER LAKES PLLC
Entity Type:Organization
Organization Name:PRIME MEDICAL OF THE FINGER LAKES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARBEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOUSSALLEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-663-7259
Mailing Address - Street 1:1150 STATE ROUTE 5 AND 20
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-9543
Mailing Address - Country:US
Mailing Address - Phone:315-759-5319
Mailing Address - Fax:315-759-5339
Practice Address - Street 1:1150 STATE ROUTE 5 AND 20
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-9543
Practice Address - Country:US
Practice Address - Phone:315-759-5319
Practice Address - Fax:315-759-5339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232779-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03358610Medicaid
NY03358610Medicaid