Provider Demographics
NPI:1174719629
Name:RAIMAH PRIMARY CARE CENTER PA
Entity type:Organization
Organization Name:RAIMAH PRIMARY CARE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAIME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-754-0339
Mailing Address - Street 1:1283 SW STATE ROAD 47
Mailing Address - Street 2:SUITE103
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0489
Mailing Address - Country:US
Mailing Address - Phone:386-754-0339
Mailing Address - Fax:386-754-0393
Practice Address - Street 1:1283 SW STATE ROAD 47
Practice Address - Street 2:103
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0489
Practice Address - Country:US
Practice Address - Phone:386-754-0339
Practice Address - Fax:386-754-0393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85010207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264300600Medicaid
FLH04412Medicare UPIN
FL264300600Medicaid