Basic Information
| Provider Information | |||||||||
| NPI: | 1033695820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRIMUS | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | LEONARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
| FaxNumber: | 2172773960 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
| FaxNumber: | 2172773960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2018 | ||||||||
| LastUpdateDate: | 10/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 036153623 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.