=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063128262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME PHYSICIAN GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2023
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 FAULKNER WAY
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15601-9044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-853-6847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 FAULKNER WAY
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15601-9044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-853-6847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | JUDE ELIAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 724-853-6847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------