Provider Demographics
NPI:1861688814
Name:PRIMECARE MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:PRIMECARE MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:AK
Authorized Official - Last Name:MOOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-830-5080
Mailing Address - Street 1:2869 WILSHIRE DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-3282
Mailing Address - Country:US
Mailing Address - Phone:407-295-0500
Mailing Address - Fax:407-290-2997
Practice Address - Street 1:2869 WILSHIRE DR
Practice Address - Street 2:SUITE 205
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-3282
Practice Address - Country:US
Practice Address - Phone:407-295-0500
Practice Address - Fax:407-290-2997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-23
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42524AOtherINDIVIDUAL MC PROVIDER #
FL42524AOtherINDIVIDUAL MC PROVIDER #
FLK2454Medicare PIN