Basic Information
| Provider Information | |||||||||
| NPI: | 1063659902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALBARCHA PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15134 CLAYTON RD | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630177046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183559970 | ||||||||
| FaxNumber: | 6183559972 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182337750 | ||||||||
| FaxNumber: | 6183559972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2009 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALBARCHA | ||||||||
| AuthorizedOfficialFirstName: | BASSAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6183559970 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036096687 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036096687 | 05 | IL | MEDICAID |