Healthcare Provider Details

I. General information

NPI: 1659815074
Provider Name (Legal Business Name): PRIME MEDICAL CLINIC S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 W LAKE AVE STE 307
GLENVIEW IL
60026-5803
US

IV. Provider business mailing address

333 W DUNDEE RD
BUFFALO GROVE IL
60089-3545
US

V. Phone/Fax

Practice location:
  • Phone: 847-626-8722
  • Fax: 847-316-9502
Mailing address:
  • Phone: 847-243-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036135325
License Number StateIL

VIII. Authorized Official

Name: DR. KONSTANTINS KOCIASVILI
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 773-507-7434