Provider Demographics
NPI:1184380099
Name:IMAGINE PRIMARY CARE, PC
Entity type:Organization
Organization Name:IMAGINE PRIMARY CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PODKOWA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:774-264-0932
Mailing Address - Street 1:4 BRIGGS LANE CT
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MA
Mailing Address - Zip Code:02738-1681
Mailing Address - Country:US
Mailing Address - Phone:774-264-0932
Mailing Address - Fax:
Practice Address - Street 1:370 FAUNCE CORNER RD STE 103
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1271
Practice Address - Country:US
Practice Address - Phone:774-264-0932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1932373552OtherNPI
MA1285621300OtherNPI
MA1457808024OtherNPI
MA1750361713OtherNPI