Provider Demographics
NPI:1003120387
Name:PC ASSOCIATE, LLC
Entity Type:Organization
Organization Name:PC ASSOCIATE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-257-4644
Mailing Address - Street 1:4500 MEMORIAL DR
Mailing Address - Street 2:MEDICAL AFFAIRS CREDENTIALING DEPARTMENT
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5360
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:618-257-6946
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:STE 160
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5368
Practice Address - Country:US
Practice Address - Phone:618-235-0460
Practice Address - Fax:618-235-1464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PC ASSOCIATE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-29
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty