Healthcare Provider Details

I. General information

NPI: 1023837689
Provider Name (Legal Business Name): PRIME HEALTHCARE ILLINOIS MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 E DEMPSTER ST
DES PLAINES IL
60016-4839
US

IV. Provider business mailing address

2380 E DEMPSTER ST
DES PLAINES IL
60016-4839
US

V. Phone/Fax

Practice location:
  • Phone: 833-291-0464
  • Fax:
Mailing address:
  • Phone: 833-291-0464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTOPHER DOAN
Title or Position: MANAGING ASSOCIATE GENERAL COUNSEL
Credential:
Phone: 310-259-4706