Provider Demographics
NPI:1205332111
Name:PRIME MED MEDICAL SERVICES PC
Entity type:Organization
Organization Name:PRIME MED MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PRABASH
Authorized Official - Middle Name:
Authorized Official - Last Name:KONERU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-276-8866
Mailing Address - Street 1:2114 PACIFIC BLVD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1139
Mailing Address - Country:US
Mailing Address - Phone:347-276-8866
Mailing Address - Fax:
Practice Address - Street 1:1676 N OLDEN AVE
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08638-3209
Practice Address - Country:US
Practice Address - Phone:347-276-8866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty