PRIMESOURCE HEALTHCARE SYSTEMS, INC.

Provider Demographics

• NPI: 1497704126
• Name: PRIMESOURCE HEALTHCARE SYSTEMS, INC.
• Entity Type: Organization
• Organization Name: PRIMESOURCE HEALTHCARE SYSTEMS, INC.
• Authorized Official - Title/Position: PRESIDENT & CEO
• Authorized Official - Prefix: MR
• Authorized Official - First Name: DAVID
• Authorized Official - Last Name: FLEMING
• Authorized Official - Phone: 800-317-0711
• Mailing Address - Street 1: 2100 EAST LAKE COOK ROAD
• Mailing Address - Street 2: SUITE 1100
• Mailing Address - City: BUFFALO GROVE
• Mailing Address - State: IL
• Mailing Address - Zip Code: 60089-1815
• Mailing Address - Country: US
• Mailing Address - Phone: 800-317-0711
• Mailing Address - Fax: 877-821-6402
• Practice Address - Street 1: 2100 EAST LAKE COOK ROAD
• Practice Address - Street 2: SUITE 1100
• Practice Address - City: BUFFALO GROVE
• Practice Address - State: IL
• Practice Address - Zip Code: 60089-1815
• Practice Address - Country: US
• Practice Address - Phone: 800-317-0711
• Practice Address - Fax: 877-821-6402
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-05-09
• Last Update Date: 2014-02-19

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	213E00000X	Podiatric Medicine & Surgery Service Providers	Podiatrist		Group - Multi-Specialty
No	122300000X	Dental Providers	Dentist		Group - Multi-Specialty
No	1223G0001X	Dental Providers	Dentist	General Practice	Group - Multi-Specialty
No	152W00000X	Eye and Vision Services Providers	Optometrist		Group - Multi-Specialty
No	152WV0400X	Eye and Vision Services Providers	Optometrist	Vision Therapy	Group - Multi-Specialty
No	231H00000X	Speech, Language and Hearing Service Providers	Audiologist		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	100052700	Medicaid
IN	200109050	Medicaid
IN	000000175113	Other	ANTHEM
IN	200378850A	Medicaid
IN	054580	Medicare PIN
IN	CE8521	Medicare PIN
IN	100052700	Medicaid
IN	200378850A	Medicaid