Provider Demographics
NPI:1427228642
Name:PRIME CARE MEDICAL CENTER SC
Entity Type:Organization
Organization Name:PRIME CARE MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:TZANETAKOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-897-2848
Mailing Address - Street 1:99 BOULDER HILL PASS
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-1911
Mailing Address - Country:US
Mailing Address - Phone:630-897-2848
Mailing Address - Fax:630-897-4498
Practice Address - Street 1:99 BOULDER HILL PASS
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-1911
Practice Address - Country:US
Practice Address - Phone:630-897-2848
Practice Address - Fax:630-897-4498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207Q00000X, 207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty