Provider Demographics
NPI:1750418299
Name:PRIMARY CARE MEDICAL SERVICES
Entity type:Organization
Organization Name:PRIMARY CARE MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENTD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE-ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-517-9166
Mailing Address - Street 1:PO BOX 848127
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33084-0127
Mailing Address - Country:US
Mailing Address - Phone:954-517-9166
Mailing Address - Fax:954-517-9167
Practice Address - Street 1:10000 STIRLING RD
Practice Address - Street 2:SUITE 3
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-8067
Practice Address - Country:US
Practice Address - Phone:954-517-9166
Practice Address - Fax:954-517-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69293207R00000X
FLME79139208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74888OtherBCBS
FL74888OtherBCBS