Basic Information
| Provider Information | |||||||||
| NPI: | 1033625959 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PC ASSOCIATE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 4600 MEMORIAL DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182350460 | ||||||||
| FaxNumber: | 6182351464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2017 | ||||||||
| LastUpdateDate: | 12/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6182574644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.