Healthcare Provider Details

I. General information

NPI: 1215029467
Provider Name (Legal Business Name): FIFTH AVE PRIMARY CARE PHYSICIANS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 FOXFIELD RD SUITE 100
ST CHARLES IL
60174-1406
US

IV. Provider business mailing address

2570 FOXFIELD RD SUITE 100
ST CHARLES IL
60174-1406
US

V. Phone/Fax

Practice location:
  • Phone: 630-584-1950
  • Fax: 630-584-8994
Mailing address:
  • Phone: 630-584-1950
  • Fax: 630-584-8994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-003468
License Number StateIL

VIII. Authorized Official

Name: DR. CATHERINE S THOMAS
Title or Position: OWNER
Credential: M.D.
Phone: 630-584-1950