Healthcare Provider Details

I. General information

NPI: 1861137135
Provider Name (Legal Business Name): PRIME HEALTH SYSTEM ,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 N CLARK ST STE 647
CHICAGO IL
60610-5469
US

IV. Provider business mailing address

1030 N CLARK ST STE 647
CHICAGO IL
60610-5469
US

V. Phone/Fax

Practice location:
  • Phone: 847-810-9095
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LIELA MAATOUK
Title or Position: ADMINISTRATOR
Credential:
Phone: 847-730-7098