Provider Demographics
NPI:1750324521
Name:PRIME CARE MEDICAL CENTER PC
Entity Type:Organization
Organization Name:PRIME CARE MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-645-7932
Mailing Address - Street 1:1 PRIME CARE DR
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-1864
Mailing Address - Country:US
Mailing Address - Phone:731-645-7932
Mailing Address - Fax:
Practice Address - Street 1:1 PRIME CARE DR
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1864
Practice Address - Country:US
Practice Address - Phone:731-645-7932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3717104Medicaid
CG1877OtherRAILROAD MEDICARE
TN3717101Medicaid
TN3717102Medicaid
TN3717104Medicare PIN
TN3717102Medicaid
TN1294860002Medicare NSC
TN3717102Medicare PIN
TN1294860001Medicare NSC
TN3717104Medicaid