Healthcare Provider Details

I. General information

NPI: 1184819302
Provider Name (Legal Business Name): PRIME HEALTHCARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JORDAN LN
WETHERSFIELD CT
06109-1278
US

IV. Provider business mailing address

30 JORDAN LN
WETHERSFIELD CT
06109-1278
US

V. Phone/Fax

Practice location:
  • Phone: 860-263-0253
  • Fax: 860-263-0262
Mailing address:
  • Phone: 860-263-0253
  • Fax: 860-263-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number54316
License Number StateCT
# 12
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier004201480
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer
# 2
Identifier008058707
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer
# 3
Identifier004185147
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name: SUSAN ALBANO
Title or Position: CEO
Credential:
Phone: 860-263-0253