Healthcare Provider Details

I. General information

NPI: 1124298443
Provider Name (Legal Business Name): PRIME HEALTH MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 GARNET DR
DAYTON OH
45458-2141
US

IV. Provider business mailing address

8120 GARNET DR
DAYTON OH
45458-2141
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-2511
  • Fax: 937-291-2523
Mailing address:
  • Phone: 937-291-2511
  • Fax: 937-291-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number35-068963
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1982
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number350868963G
License Number StateOH

VIII. Authorized Official

Name: DR. LAILA GOMAA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 937-291-2511