Provider Demographics
NPI:1790819373
Name:PRESTIGE PRIMARY CARE ASSOCIATES, PLLC
Entity type:Organization
Organization Name:PRESTIGE PRIMARY CARE ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-768-0700
Mailing Address - Street 1:4501 MACCORKLE AVE SW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1444
Mailing Address - Country:US
Mailing Address - Phone:304-768-0700
Mailing Address - Fax:304-768-9790
Practice Address - Street 1:4501 MACCORKLE AVE SW
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1444
Practice Address - Country:US
Practice Address - Phone:304-768-0700
Practice Address - Fax:304-768-9790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1390207R00000X
WV1212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007578Medicaid
WV9325431Medicare PIN