Provider Demographics
NPI:1861615452
Name:PRIME MEDICAL GROUP PC
Entity type:Organization
Organization Name:PRIME MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:AQEL
Authorized Official - Last Name:ELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-720-3370
Mailing Address - Street 1:4455 TOWN CENTER PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3425
Mailing Address - Country:US
Mailing Address - Phone:810-720-3370
Mailing Address - Fax:810-720-3367
Practice Address - Street 1:4455 TOWN CENTER PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3425
Practice Address - Country:US
Practice Address - Phone:810-720-3370
Practice Address - Fax:810-720-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085958207RI0011X
MI51010164432084S0012X
MI43010629942086S0129X
MI4704216332363L00000X
MI4301075121207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4618140Medicaid
MI0N95010Medicare ID - Type UnspecifiedMEDICARE
MI4618140Medicaid