Healthcare Provider Details

I. General information

NPI: 1720667637
Provider Name (Legal Business Name): PCAC GI JV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 W SURF ST STE 506
CHICAGO IL
60657-7227
US

IV. Provider business mailing address

331 W SURF ST STE 506
CHICAGO IL
60657-7227
US

V. Phone/Fax

Practice location:
  • Phone: 317-504-9628
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEAN LEHMKUHLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 317-504-9628