Provider Demographics
NPI:1770770919
Name:THE CENTER FOR INTERNAL MEDICINE AND PREVENTIVE CARE S C
Entity type:Organization
Organization Name:THE CENTER FOR INTERNAL MEDICINE AND PREVENTIVE CARE S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-814-2728
Mailing Address - Street 1:501 N RIVERSIDE DR STE 216
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5918
Mailing Address - Country:US
Mailing Address - Phone:847-625-8300
Mailing Address - Fax:847-625-8862
Practice Address - Street 1:501 N RIVERSIDE DR
Practice Address - Street 2:SUITE 216
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5918
Practice Address - Country:US
Practice Address - Phone:847-625-8300
Practice Address - Fax:847-625-8862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097015207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110241112OtherPALMETTO GBA
ILG93759Medicare UPIN
IL211292Medicare PIN