Healthcare Provider Details

I. General information

NPI: 1992851067
Provider Name (Legal Business Name): PRIMECARE COMMUNITY HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 W FULLERTON AVE
CHICAGO IL
60647-2228
US

IV. Provider business mailing address

1431 N. WESTERN AVE. SUITE #401
CHICAGO IL
60622-1797
US

V. Phone/Fax

Practice location:
  • Phone: 773-276-2229
  • Fax: 773-276-2190
Mailing address:
  • Phone: 312-633-5841
  • Fax: 312-491-5485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH MOLDOVAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 312-491-5034