Provider Demographics
NPI:1356528152
Name:PRIME MEDICAL GROUP
Entity type:Organization
Organization Name:PRIME MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PRACTIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBARAM
Authorized Official - Middle Name:V
Authorized Official - Last Name:CHAUHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-929-4930
Mailing Address - Street 1:PO BOX 18619
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-0619
Mailing Address - Country:US
Mailing Address - Phone:724-929-4930
Mailing Address - Fax:724-929-4308
Practice Address - Street 1:1200 BROOKS LN
Practice Address - Street 2:SUITE 110
Practice Address - City:CLAIRTON
Practice Address - State:PA
Practice Address - Zip Code:15025-3747
Practice Address - Country:US
Practice Address - Phone:724-929-4930
Practice Address - Fax:724-929-4308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037996L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007726550009Medicaid
PA769210OtherHIGHMARK BLUE SHIELD
PA331905OtherHIGHMARK BLUE SHIELD
PA692646OtherHIGHMARK BLUE SHIELD
PA692541OtherHIGHMARK BLUE SHIELD
PA064901K55Medicare PIN
PAG93475Medicare UPIN
PA18174K55Medicare PIN
PA074417K55Medicare PIN
PA692646OtherHIGHMARK BLUE SHIELD
PAH74915Medicare UPIN