Provider Demographics
NPI:1003406000
Name:PREMIER PRIMARY CARE AND ALTERNATIVE MEDICINE
Entity Type:Organization
Organization Name:PREMIER PRIMARY CARE AND ALTERNATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUTLAND
Authorized Official - Suffix:I
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:574-276-7184
Mailing Address - Street 1:1301 E 47TH STREET
Mailing Address - Street 2:BLDG 2 SUITE B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653
Mailing Address - Country:US
Mailing Address - Phone:773-891-2890
Mailing Address - Fax:773-891-4107
Practice Address - Street 1:1301 E 47TH STREET
Practice Address - Street 2:BLDG 2 SUITE B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653
Practice Address - Country:US
Practice Address - Phone:773-891-2890
Practice Address - Fax:773-891-4107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER HEALTH NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-22
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty