Provider Demographics
NPI:1750575940
Name:PRIMARY CARE WEST, S.C.
Entity type:Organization
Organization Name:PRIMARY CARE WEST, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMBARD
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:630-897-6851
Mailing Address - Street 1:1300 N HIGHLAND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1464
Mailing Address - Country:US
Mailing Address - Phone:630-897-9600
Mailing Address - Fax:630-897-9625
Practice Address - Street 1:1300 N HIGHLAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1464
Practice Address - Country:US
Practice Address - Phone:630-897-9600
Practice Address - Fax:630-897-9625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085384207R00000X
IL036088055207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
001630376OtherBCBS
IL201715OtherMEDICARE GROUP
F98616Medicare UPIN
001630376OtherBCBS
IL201715OtherMEDICARE GROUP
L91485Medicare PIN