Provider Demographics
NPI:1114458791
Name:PHYSICIAN CARE AT HOME MANAGEMENT COMPANY LLC
Entity Type:Organization
Organization Name:PHYSICIAN CARE AT HOME MANAGEMENT COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-307-2648
Mailing Address - Street 1:1026 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1712
Mailing Address - Country:US
Mailing Address - Phone:773-307-2648
Mailing Address - Fax:
Practice Address - Street 1:1026 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1712
Practice Address - Country:US
Practice Address - Phone:773-307-2648
Practice Address - Fax:773-942-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099959Medicaid