Provider Demographics
NPI:1659815074
Name:PRIME MEDICAL CLINIC S.C.
Entity Type:Organization
Organization Name:PRIME MEDICAL CLINIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KONSTANTINS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCIASVILI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-507-7434
Mailing Address - Street 1:333 W DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3545
Mailing Address - Country:US
Mailing Address - Phone:847-243-0355
Mailing Address - Fax:
Practice Address - Street 1:3633 W LAKE AVE STE 307
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5803
Practice Address - Country:US
Practice Address - Phone:847-626-8722
Practice Address - Fax:847-316-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135325207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036135325Medicaid