Provider Demographics
NPI:1942303078
Name:PRIME CARE MEDICAL SERVICES
Entity Type:Organization
Organization Name:PRIME CARE MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUGBENGA
Authorized Official - Middle Name:
Authorized Official - Last Name:AWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-408-2555
Mailing Address - Street 1:827 TIQUA TRL
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-4705
Mailing Address - Country:US
Mailing Address - Phone:419-331-9797
Mailing Address - Fax:
Practice Address - Street 1:825 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2799
Practice Address - Country:US
Practice Address - Phone:419-331-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073659A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2031607Medicaid
OH9344181Medicare ID - Type Unspecified