Provider Demographics
NPI:1881903532
Name:PRIMARY CARE GROUP 12, INC.,
Entity type:Organization
Organization Name:PRIMARY CARE GROUP 12, INC.,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:UMBERTO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DERIENZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-483-3581
Mailing Address - Street 1:17 ARENTZEN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-1085
Mailing Address - Country:US
Mailing Address - Phone:724-483-3581
Mailing Address - Fax:724-483-3483
Practice Address - Street 1:17 ARENTZEN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLEROI
Practice Address - State:PA
Practice Address - Zip Code:15022-1085
Practice Address - Country:US
Practice Address - Phone:724-483-3581
Practice Address - Fax:724-483-3483
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-29
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053835L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty