Provider Demographics
NPI:1295923191
Name:HERITAGE PRIMARY CARE, S.C.
Entity type:Organization
Organization Name:HERITAGE PRIMARY CARE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARCHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-488-9589
Mailing Address - Street 1:1600 N RANDALL RD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7803
Mailing Address - Country:US
Mailing Address - Phone:847-488-9589
Mailing Address - Fax:847-931-5173
Practice Address - Street 1:1600 N RANDALL RD
Practice Address - Street 2:SUITE 155
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7803
Practice Address - Country:US
Practice Address - Phone:847-488-9589
Practice Address - Fax:847-931-5173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004522347OtherBCBS
IL036092129Medicaid
IL0004522347OtherBCBS
G41526Medicare UPIN