Healthcare Provider Details

I. General information

NPI: 1588731764
Provider Name (Legal Business Name): PRIMARY CARE ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6840 WINDSOR AVE
BERWYN IL
60402-3441
US

IV. Provider business mailing address

6840 WINDSOR AVE
BERWYN IL
60402-3441
US

V. Phone/Fax

Practice location:
  • Phone: 708-484-0042
  • Fax: 708-749-5489
Mailing address:
  • Phone: 708-484-0042
  • Fax: 708-749-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRADFORD WAINER
Title or Position: PHYSICIAN
Credential: DO
Phone: 708-484-0042