MEDICARE: PRIME PATH MEDICAL GROUP MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1396625612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME PATH MEDICAL GROUP MD

Provider Business Mailing Address
First Line	:	1500 S CENTRAL AVE STE 323
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-3858
Country	:	US
Telephone Number	:	747-200-6948
Fax Number	:	747-800-8005

Provider Business Practice Location Address
First Line	:	1500 S CENTRAL AVE STE 323
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-3858
Country	:	US
Telephone Number	:	747-200-6948
Fax Number	:	747-800-8005

Authorized Official
Title or Position	:	MD, CO-OWNER, PREDIDENT
Name	:	DR. MASON ALEXANDER BRAGG
Credential	:
Telephone Number	:	747-800-8005

Provider Enumeration Date	:	09/05/2025
Last Update Date	:	09/05/2025

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