Healthcare Provider Details

I. General information

NPI: 1497704126
Provider Name (Legal Business Name): PRIMESOURCE HEALTHCARE SYSTEMS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 EAST LAKE COOK ROAD SUITE 1100
BUFFALO GROVE IL
60089-1815
US

IV. Provider business mailing address

2100 EAST LAKE COOK ROAD SUITE 1100
BUFFALO GROVE IL
60089-1815
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 TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID FLEMING
Title or Position: PRESIDENT & CEO
Credential:
Phone: 800-317-0711