Provider Demographics
NPI:1912473604
Name:PRIMARY CARE PHYSICIANS OF JOLIET SC
Entity Type:Organization
Organization Name:PRIMARY CARE PHYSICIANS OF JOLIET SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MITI
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-726-2200
Mailing Address - Street 1:2025 S CHICAGO ST STE 1
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60436-3173
Mailing Address - Country:US
Mailing Address - Phone:815-726-2200
Mailing Address - Fax:
Practice Address - Street 1:2025 S CHICAGO ST STE 1
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-3173
Practice Address - Country:US
Practice Address - Phone:815-726-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty