Basic Information
| Provider Information | |||||||||
| NPI: | 1063844934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY HEALTHCARE ASSOCIATES, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 159TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604771758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089156314 | ||||||||
| FaxNumber: | 7089152706 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 159TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604771758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089156314 | ||||||||
| FaxNumber: | 7089152706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 08/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | PORFIRIO | ||||||||
| AuthorizedOfficialFirstName: | TAMARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 7089156314 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 036047581 | IL | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.