Basic Information
Provider Information
NPI: 1396142139
EntityType: 2
ReplacementNPI:  
OrganizationName: PC ASSOCIATES, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: MEMORIAL MEDICAL GROUP AFTER HOURS CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4500 MEMORIAL DRIVE
Address2: MEMORIAL HOSPITAL MEDICAL AFFAIRS CREDENTIALING DEPT
City: BELLEVILLE
State: IL
PostalCode: 62226
CountryCode: US
TelephoneNumber: 6182574644
FaxNumber:  
Practice Location
Address1: 310 N SEVEN HILLS RD
Address2:  
City: O FALLON
State: IL
PostalCode: 622694111
CountryCode: US
TelephoneNumber: 6186222581
FaxNumber: 6186222593
Other Information
ProviderEnumerationDate: 11/21/2014
LastUpdateDate: 06/14/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DAVIS
AuthorizedOfficialFirstName: JAMES
AuthorizedOfficialMiddleName: B
AuthorizedOfficialTitleorPosition: EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 6186222581
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X  N193400000X MULTIPLE SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 
207Q00000X  Y193400000X MULTIPLE SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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