Basic Information
Provider Information | |||||||||
NPI: | 1437462637 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PC ASSOCIATES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23830 | ||||||||
Address2: |   | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622230830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182229999 | ||||||||
FaxNumber: | 6182229337 | ||||||||
Practice Location | |||||||||
Address1: | 325 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | DUPO | ||||||||
State: | IL | ||||||||
PostalCode: | 622391325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182865251 | ||||||||
FaxNumber: | 6182865677 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2010 | ||||||||
LastUpdateDate: | 07/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | VP MEDICAL STAFF SERVICES | ||||||||
AuthorizedOfficialTelephone: | 6182576302 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | FACHE, MBA, MHSA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.