Provider Demographics
NPI:1912113002
Name:PRIMARY CARE MEDICAL PRACTICE, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE MEDICAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ISSAM
Authorized Official - Last Name:MALLOUHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-237-9055
Mailing Address - Street 1:1031 MCBRIDE AVE
Mailing Address - Street 2:SUITE D 205
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2559
Mailing Address - Country:US
Mailing Address - Phone:973-237-9055
Mailing Address - Fax:973-237-9053
Practice Address - Street 1:1031 MCBRIDE AVE
Practice Address - Street 2:SUITE D 205
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-2559
Practice Address - Country:US
Practice Address - Phone:973-237-9055
Practice Address - Fax:973-237-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA061762174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
065655Medicare UPIN