Provider Demographics
NPI:1902202757
Name:CENTEGRA PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:CENTEGRA PRIMARY CARE, LLC
Other - Org Name:CENTEGRA PHYSICIAN CARE DEL WEBB
Other - Org Type:Other Name
Authorized Official - Title/Position:EVP, CFO & CIO
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 1:12920 DEL WEBB BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-7602
Mailing Address - Country:US
Mailing Address - Phone:815-515-2078
Mailing Address - Fax:815-515-2334
Practice Address - Street 1:12920 DEL WEBB BLVD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-7602
Practice Address - Country:US
Practice Address - Phone:815-515-2078
Practice Address - Fax:815-515-2334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTEGRA PRIMARY CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site