Basic Information
| Provider Information | |||||||||
| NPI: | 1235452855 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PC ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 MEMORIAL DRIVE | ||||||||
| Address2: | MEDICAL AFFAIRS OFFICE | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182574644 | ||||||||
| FaxNumber: | 6182576946 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 NORTH SEVEN HILLS ROAD | ||||||||
| Address2: | |||||||||
| City: | O'FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186246181 | ||||||||
| FaxNumber: | 6186222593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6182576301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FACHE, MBA, MHSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 207R00000X | 036053136 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.