Healthcare Provider Details

I. General information

NPI: 1750575940
Provider Name (Legal Business Name): PRIMARY CARE WEST, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N HIGHLAND AVE STE 2
AURORA IL
60506-1464
US

IV. Provider business mailing address

1300 N HIGHLAND AVE STE 2
AURORA IL
60506-1464
US

V. Phone/Fax

Practice location:
  • Phone: 630-897-9600
  • Fax: 630-897-9625
Mailing address:
  • Phone: 630-897-9600
  • Fax: 630-897-9625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036085384
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036088055
License Number StateIL

VIII. Authorized Official

Name: TINA BOMBARD III
Title or Position: BILLING DIRECTOR
Credential:
Phone: 630-897-6851