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General NPI Number Information
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NPI Number | 1639437684
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Entity Type | Organization
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Legal Business Name | PREMIER WELLCARE, INC.
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Dates
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Enumeration Date | 04/27/2012
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Last Update Date | 05/22/2012
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Provider Practice Location Address
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Address Line | 400 W. HIGGINS RD.
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City | PARK RIDGE
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State | IL
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Zip | 60068
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Country | US
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Telephone | 312-898-5064
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Fax |
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Provider Business Mailing Address
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Address Line | 115 S LA SALLE ST SUITE 2600
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City | CHICAGO
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State | IL
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Zip | 60603-3801
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Country | US
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Telephone | 312-898-5064
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Fax |
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Authorized Official
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Title or Position | WELLNESS PROGRAM MANAGER
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Name | SAMANTHA A. VASICH
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Credential |
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Telephone | 312-898-5064
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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