Provider Demographics
NPI: | 1245571108 |
---|---|
Name: | PRIME HOME CARE MIDWAY, INC |
Entity Type: | Organization |
Organization Name: | PRIME HOME CARE MIDWAY, INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CHIEF LEGAL OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOSEPH |
Authorized Official - Middle Name: | PATRICK |
Authorized Official - Last Name: | BONACCORSI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 312-762-9999 |
Mailing Address - Street 1: | 33 S STATE ST FL 5 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60603-2804 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 312-762-9999 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1342 W. 4TH STREET |
Practice Address - Street 2: | |
Practice Address - City: | MANSFIELD |
Practice Address - State: | OH |
Practice Address - Zip Code: | 44906-1828 |
Practice Address - Country: | US |
Practice Address - Phone: | 419-529-0900 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | RITECHOICE HEALTHCARE SERVICES. LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2013-03-01 |
Last Update Date: | 2022-09-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251E00000X | Agencies | Home Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0109512 | Medicaid |