Healthcare Provider Details

I. General information

NPI: 1255834446
Provider Name (Legal Business Name): ILLINOIS PRIMARY URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E BROADWAY STE B
MONMOUTH IL
61462-1995
US

IV. Provider business mailing address

2026 62ND ST
MONMOUTH IL
61462-9054
US

V. Phone/Fax

Practice location:
  • Phone: 309-337-0736
  • Fax:
Mailing address:
  • Phone: 309-337-0736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036127590
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number036127590
License Number StateIL

VIII. Authorized Official

Name: DR. ABDUL WAHID ROYEEN
Title or Position: OWNER
Credential: MD
Phone: 309-337-0736