Basic Information
| Provider Information | |||||||||
| NPI: | 1770984528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMARY CARE PARTNERS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINE BROOK MEDICAL CENTER-PRIMARY CARE PARTNERS AFFILIATE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2403 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080436403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567823300 | ||||||||
| FaxNumber: | 8565048029 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 CHANGEBRIDGE RD | ||||||||
| Address2: | SUITE A3 | ||||||||
| City: | MONTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070459115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738083200 | ||||||||
| FaxNumber: | 9738083202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2014 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHULKIN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8567823300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMARY CARE PARTNERS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.