Provider Demographics
NPI:1992851067
Name:PRIMECARE COMMUNITY HEALTH, INC.
Entity Type:Organization
Organization Name:PRIMECARE COMMUNITY HEALTH, INC.
Other - Org Name:PRIMECARE FULLERTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLDOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-491-5034
Mailing Address - Street 1:1431 N. WESTERN AVE.
Mailing Address - Street 2:SUITE #401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:312-633-5841
Mailing Address - Fax:312-491-5485
Practice Address - Street 1:3924 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2228
Practice Address - Country:US
Practice Address - Phone:773-276-2229
Practice Address - Fax:773-276-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========010Medicaid
IL=========010Medicaid
IL324020Medicare Oscar/Certification