Healthcare Provider Details

I. General information

NPI: 1124013040
Provider Name (Legal Business Name): PRIME CARE PHYSICIANS, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 GLENN POND ROAD SUITE 3
RED HOOK NY
12571-1824
US

IV. Provider business mailing address

17 GLENN POND ROAD SUITE 3
RED HOOK NY
12571-1824
US

V. Phone/Fax

Practice location:
  • Phone: 845-758-6046
  • Fax: 845-758-6051
Mailing address:
  • Phone: 845-758-6046
  • Fax: 845-758-6051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANGELA C CAVANNA
Title or Position: DIRECTOR
Credential: DO
Phone: 845-758-6046