Provider Demographics
NPI:1396625612
Name:PRIME PATH MEDICAL GROUP MD
Entity type:Organization
Organization Name:PRIME PATH MEDICAL GROUP MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, CO-OWNER, PREDIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MASON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-800-8005
Mailing Address - Street 1:1500 S CENTRAL AVE STE 323
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3858
Mailing Address - Country:US
Mailing Address - Phone:747-200-6948
Mailing Address - Fax:747-800-8005
Practice Address - Street 1:1500 S CENTRAL AVE STE 323
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-3858
Practice Address - Country:US
Practice Address - Phone:747-200-6948
Practice Address - Fax:747-800-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty