Provider Demographics
NPI:1255799961
Name:PRIMARYMD
Entity type:Organization
Organization Name:PRIMARYMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLASENAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:864-305-5000
Mailing Address - Street 1:2498 N. PLEASANTBURG DR.
Mailing Address - Street 2:SUITE D
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609
Mailing Address - Country:US
Mailing Address - Phone:864-305-5000
Mailing Address - Fax:864-840-8207
Practice Address - Street 1:2498 N PLEASANTBURG DR
Practice Address - Street 2:SUITE D
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-2730
Practice Address - Country:US
Practice Address - Phone:864-305-5000
Practice Address - Fax:864-840-8207
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMERGENCYMD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty