Provider Demographics
NPI:1568904597
Name:CENTEGRA PRIMARY CARE LLC
Entity Type:Organization
Organization Name:CENTEGRA PRIMARY CARE LLC
Other - Org Name:CENTEGRA PHYSICIAN CARE MCHENRY COUNTY ORTHOPEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CIO & CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-788-5831
Mailing Address - Street 1:10370 HALIGUS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142
Mailing Address - Country:US
Mailing Address - Phone:815-356-5200
Mailing Address - Fax:815-356-5262
Practice Address - Street 1:10370 HALIGUS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142
Practice Address - Country:US
Practice Address - Phone:815-356-5200
Practice Address - Fax:815-356-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7574980001Medicare NSC