Basic Information
| Provider Information | |||||||||
| NPI: | 1427228642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME CARE MEDICAL CENTER SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 BOULDER HILL PASS | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605381911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308972848 | ||||||||
| FaxNumber: | 6308974498 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 BOULDER HILL PASS | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605381911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308972848 | ||||||||
| FaxNumber: | 6308974498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | TZANETAKOS | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | GEORGE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6308972848 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.