Provider Demographics
NPI:1134386410
Name:PRIMARY CARE MEDICAL GROUP PA
Entity type:Organization
Organization Name:PRIMARY CARE MEDICAL GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:D'AGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-484-6900
Mailing Address - Street 1:450 BERGEN ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-2291
Mailing Address - Country:US
Mailing Address - Phone:973-484-6900
Mailing Address - Fax:973-484-0029
Practice Address - Street 1:450 BERGEN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NJ
Practice Address - Zip Code:07029-2291
Practice Address - Country:US
Practice Address - Phone:973-484-6900
Practice Address - Fax:973-484-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31348207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ527007Medicare PIN