Provider Demographics
NPI:1932339926
Name:PRIMECARE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PRIMECARE MEDICAL GROUP LLC
Other - Org Name:PRIMECARE MEDICAL OF LAND O LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REVELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-932-0996
Mailing Address - Street 1:2638 NARNIA WAY UNIT 101
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-7321
Mailing Address - Country:US
Mailing Address - Phone:813-909-0760
Mailing Address - Fax:813-949-7394
Practice Address - Street 1:2638 NARNIA WAY UNIT 101
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-7321
Practice Address - Country:US
Practice Address - Phone:813-909-0760
Practice Address - Fax:813-949-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty