Provider Demographics
NPI: | 1467442293 |
---|---|
Name: | PRIMARY HEALTHCARE ASSOCIATES SC |
Entity Type: | Organization |
Organization Name: | PRIMARY HEALTHCARE ASSOCIATES SC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | KURT |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | JOHNSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 708-915-6364 |
Mailing Address - Street 1: | 27702 NETWORK PL |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60673-1277 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 708-862-7674 |
Mailing Address - Fax: | 708-862-1781 |
Practice Address - Street 1: | 71 W 156TH ST |
Practice Address - Street 2: | 5TH FLOOR |
Practice Address - City: | HARVEY |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60426-4260 |
Practice Address - Country: | US |
Practice Address - Phone: | 708-915-6353 |
Practice Address - Fax: | 708-915-2706 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-10-24 |
Last Update Date: | 2020-09-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207Q00000X, 207RE0101X, 207V00000X, 207X00000X | ||
IL | 207R00000X, 207RC0000X, 207RG0300X, 207RH0003X, 207RI0011X, 2081P2900X, 208M00000X, 363A00000X, 363L00000X | |
IL | 036-048841 | 207VG0400X |
IL | 036-108069 | 207Y00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | Group - Multi-Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | Group - Multi-Specialty |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 231206 | Medicare PIN | |
IL | CD6667 | Medicare PIN | |
IL | 231199 | Medicare PIN |