Provider Demographics
NPI:1801032164
Name:PRIMARY ACCESS MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:PRIMARY ACCESS MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-728-9600
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-0607
Mailing Address - Country:US
Mailing Address - Phone:909-971-9334
Mailing Address - Fax:909-971-9654
Practice Address - Street 1:273 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-4631
Practice Address - Country:US
Practice Address - Phone:562-728-9600
Practice Address - Fax:562-422-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54374207R00000X
CAA36774208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty