Basic Information
| Provider Information | |||||||||
| NPI: | 1881135622 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PC ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 MEMORIAL DRIVE CREDENTIALING DEPARTMENT | ||||||||
| Address2: | MEMORIAL HOSPITAL MEDICAL AFFAIRS | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182574644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 EAST HIGHWAY 50 | ||||||||
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| City: | O'FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182574644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2017 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6182574644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036131200 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.