Provider Demographics
NPI:1801230065
Name:PRIMECARE PHILADELPHIA PC
Entity Type:Organization
Organization Name:PRIMECARE PHILADELPHIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-333-6888
Mailing Address - Street 1:3542 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-2623
Mailing Address - Country:US
Mailing Address - Phone:215-333-6888
Mailing Address - Fax:215-333-3945
Practice Address - Street 1:3542 WELSH RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-2623
Practice Address - Country:US
Practice Address - Phone:215-333-6888
Practice Address - Fax:215-333-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3815716002OtherINDEPENDENCE BLUE CROSS