Healthcare Provider Details

I. General information

NPI: 1235452855
Provider Name (Legal Business Name): PC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 NORTH SEVEN HILLS ROAD
O'FALLON IL
62269
US

IV. Provider business mailing address

4500 MEMORIAL DRIVE MEDICAL AFFAIRS OFFICE
BELLEVILLE IL
62226
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-6181
  • Fax: 618-622-2593
Mailing address:
  • Phone: 618-257-4644
  • Fax: 618-257-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036053136
License Number StateIL

VIII. Authorized Official

Name: MR. JAMES B. DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential: FACHE, MBA, MHSA
Phone: 618-257-6301