Healthcare Provider Details

I. General information

NPI: 1033625959
Provider Name (Legal Business Name): PC ASSOCIATE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR STE 400
BELLEVILLE IL
62226-5366
US

IV. Provider business mailing address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-0460
  • Fax: 618-235-1464
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA K MCDONALD
Title or Position: MANAGER
Credential:
Phone: 618-257-4644