Provider Demographics
NPI:1972504363
Name:PRIMARY CARE OF SOUTH NAPERVILLE AREA SC
Entity Type:Organization
Organization Name:PRIMARY CARE OF SOUTH NAPERVILLE AREA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VINAYAK
Authorized Official - Middle Name:V
Authorized Official - Last Name:DONGRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-904-1220
Mailing Address - Street 1:1012 95TH ST
Mailing Address - Street 2:5
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5041
Mailing Address - Country:US
Mailing Address - Phone:630-904-1220
Mailing Address - Fax:630-904-0967
Practice Address - Street 1:1012 95TH ST
Practice Address - Street 2:5
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5041
Practice Address - Country:US
Practice Address - Phone:630-904-1220
Practice Address - Fax:630-904-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009932217OtherBCBS
IL036101290Medicaid
IL0009932217OtherBCBS
IL0009932217OtherBCBS