Provider Demographics
NPI:1740461334
Name:PRIME CARE MEDICAL GROUP PC
Entity type:Organization
Organization Name:PRIME CARE MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IFFAT
Authorized Official - Middle Name:ARA
Authorized Official - Last Name:SADIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-739-7400
Mailing Address - Street 1:16806 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4341
Mailing Address - Country:US
Mailing Address - Phone:718-739-7400
Mailing Address - Fax:718-739-7413
Practice Address - Street 1:16806 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4341
Practice Address - Country:US
Practice Address - Phone:718-739-7400
Practice Address - Fax:718-739-7413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-25
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230830207Q00000X
NY229868207R00000X
NY242628207RC0000X
NY244121207RC0000X
NYN005475213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02585142Medicaid
NY02491972Medicaid
NY02802188Medicaid
NY02888186Medicaid
NYU81193Medicare UPIN