Basic Information
| Provider Information | |||||||||
| NPI: | 1235171570 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIME MEDICAL LONG | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18619 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152360619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249292640 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1645 ROSTRAVER RD | ||||||||
| Address2: | |||||||||
| City: | BELLE VERNON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150129655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249292260 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | SETHMAN | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7249292640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIME MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0008635790002 | 05 | PA | MEDICAID | 1007726550009 | 05 | PA | MEDICAID | 000031306 | 01 | PA | HIGHMARK PROV NUMBER | OTHER | 0010652420006 | 05 | PA | MEDICAID | 717558 | 01 | PA | HIGHMARK | OTHER | 769210 | 01 | PA | HIGHMARK | OTHER | 0014690470004 | 05 | PA | MEDICAID | 31238 | 01 | PA | HIGHMARK | OTHER | 0006836970001 | 05 | PA | MEDICAID | 1936740 | 01 | PA | HIGHMARK | OTHER | 692541 | 01 | PA | HIGHMARK | OTHER | 692646 | 01 | PA | HIGHMARK | OTHER | 0019214160001 | 05 | PA | MEDICAID |