Provider Demographics
NPI:1124371133
Name:PCMC EAST
Entity Type:Organization
Organization Name:PCMC EAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEE-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-798-8112
Mailing Address - Street 1:5320 159TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-4705
Mailing Address - Country:US
Mailing Address - Phone:708-798-8112
Mailing Address - Fax:708-535-6396
Practice Address - Street 1:5320 159TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-4705
Practice Address - Country:US
Practice Address - Phone:708-798-8112
Practice Address - Fax:708-535-6396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty