Healthcare Provider Details

I. General information

NPI: 1912473604
Provider Name (Legal Business Name): PRIMARY CARE PHYSICIANS OF JOLIET SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 S CHICAGO ST STE 1
JOLIET IL
60436-3173
US

IV. Provider business mailing address

2025 S CHICAGO ST STE 1
JOLIET IL
60436-3173
US

V. Phone/Fax

Practice location:
  • Phone: 815-726-2200
  • Fax: 815-582-3253
Mailing address:
  • Phone: 815-726-2200
  • Fax: 815-582-3253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MITI G SHAH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 815-726-2200