Healthcare Provider Details

I. General information

NPI: 1205361110
Provider Name (Legal Business Name): PC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 BELTLINE ROAD SUITE 500
COLLINSVILLE IL
62234
US

IV. Provider business mailing address

4500 MEMORIAL DRIVE MEDICAL AFFAIRS CREDENTIALING DEPARTMENT
BELLEVILLE IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-343-6005
  • Fax: 618-343-9114
Mailing address:
  • Phone: 618-257-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036113800
License Number StateIL

VIII. Authorized Official

Name: JAMES DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-257-4644