=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164667192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMECARE MED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2008
-----------------------------------------------------
Last Update Date | 12/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 W EDMONSTON DR SUITE 401
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-1228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-762-3030
-----------------------------------------------------
Fax | 301-762-3998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 60620
-----------------------------------------------------
City | POTOMAC
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20859-0620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-762-3030
-----------------------------------------------------
Fax | 301-762-3998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR/OWNER
-----------------------------------------------------
Name | PANKAJ TALWAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 301-762-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------