Basic Information
| Provider Information | |||||||||
| NPI: | 1962459263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMECARECOMMUNITY HEALTH, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1431 N WESTERN AVE | ||||||||
| Address2: | SUITE #406 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126335841 | ||||||||
| FaxNumber: | 3124915020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1431 N WESTERN AVE | ||||||||
| Address2: | SUITE #406 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126335841 | ||||||||
| FaxNumber: | 3124915020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIN | ||||||||
| AuthorizedOfficialFirstName: | JASIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFICER | ||||||||
| AuthorizedOfficialTelephone: | 3126335841 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.