Healthcare Provider Details

I. General information

NPI: 1598984973
Provider Name (Legal Business Name): PRIMARY HEALTH CARE SPECIALISTS S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5857 W 35TH ST
CICERO IL
60804-4250
US

IV. Provider business mailing address

5857 W 35TH ST
CICERO IL
60804-4250
US

V. Phone/Fax

Practice location:
  • Phone: 708-780-1464
  • Fax: 708-780-1468
Mailing address:
  • Phone: 708-780-1464
  • Fax: 708-780-1468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036119790
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036111596
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036093980
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036093980
License Number StateIL

VIII. Authorized Official

Name: DR. HERIBERTO MARTINEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-780-1464