Provider Demographics
NPI:1215029467
Name:FIFTH AVE PRIMARY CARE PHYSICIANS SC
Entity Type:Organization
Organization Name:FIFTH AVE PRIMARY CARE PHYSICIANS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-584-1950
Mailing Address - Street 1:2570 FOXFIELD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1406
Mailing Address - Country:US
Mailing Address - Phone:630-584-1950
Mailing Address - Fax:630-584-8994
Practice Address - Street 1:2570 FOXFIELD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1406
Practice Address - Country:US
Practice Address - Phone:630-584-1950
Practice Address - Fax:630-584-8994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-003468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG53490Medicare UPIN
ILH63050Medicare UPIN