Provider Demographics
NPI:1811090905
Name:PRIME CARE MEDICAL SERVICES INC
Entity type:Organization
Organization Name:PRIME CARE MEDICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUGBENGA
Authorized Official - Middle Name:
Authorized Official - Last Name:AWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-884-3444
Mailing Address - Street 1:242 SOUTH COASTAL HWY 17
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-5231
Mailing Address - Country:US
Mailing Address - Phone:912-884-3444
Mailing Address - Fax:912-884-3456
Practice Address - Street 1:242 SOUTH COASTAL HWY 17
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-5231
Practice Address - Country:US
Practice Address - Phone:912-884-3444
Practice Address - Fax:912-884-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8433207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA714892838AMedicaid
GA714892838AMedicaid