Basic Information
| Provider Information | |||||||||
| NPI: | 1407098643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME MEDICAL GROUP PCG1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 BROAD AVE | ||||||||
| Address2: | |||||||||
| City: | BELLE VERNON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150121405 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1645 ROSTRAVER RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BELLE VERNON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150129655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249292260 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2009 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | SETHMAN | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7249292640 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD036822L | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0006836970001 | 05 | PA | MEDICAID |