Healthcare Provider Details

I. General information

NPI: 1295937555
Provider Name (Legal Business Name): GREGORY LAMAR PRIMUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7543 183RD ST
TINLEY PARK IL
60477-6208
US

IV. Provider business mailing address

7543 183RD ST
TINLEY PARK IL
60477-6208
US

V. Phone/Fax

Practice location:
  • Phone: 708-263-2000
  • Fax: 708-263-2023
Mailing address:
  • Phone: 708-263-2000
  • Fax: 708-263-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036 118611
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: