MEDICARE: PRIME HOME VISIT & TELEMEDICINE SERVICES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301104304	MI

General Provider Information

NPI Number	:	1558810077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME HOME VISIT & TELEMEDICINE SERVICES PLLC

Provider Business Mailing Address
First Line	:	3175 CHRISTY WAY S STE 1
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48603-2210
Country	:	US
Telephone Number	:	989-401-7000
Fax Number	:	989-791-1392

Provider Business Practice Location Address
First Line	:	3175 CHRISTY WAY S
Second Line	:	STE 1
City	:	SAGINAW
State	:	MI
Zip	:	48603-2210
Country	:	US
Telephone Number	:	989-401-7000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KELLIE SWARTZ
Credential	:	CEO
Telephone Number	:	989-791-2455

Provider Enumeration Date	:	09/26/2016
Last Update Date	:	02/05/2018

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