Healthcare Provider Details

I. General information

NPI: 1144619271
Provider Name (Legal Business Name): PRIMESOURCE HEALTHCARE SYSTEMS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E LAKE COOK RD SUITE 1100
BUFFALO GROVE IL
60089-1999
US

IV. Provider business mailing address

2100 E LAKE COOK RD SUITE 1100
BUFFALO GROVE IL
60089-1999
US

V. Phone/Fax

Practice location:
  • Phone: 800-317-0711
  • Fax: 877-821-6402
Mailing address:
  • Phone: 800-317-0711
  • Fax: 877-821-6402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016.003027
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: DAVID FLEMING
Title or Position: CEO/PRESIDENT
Credential:
Phone: 800-317-0711