MEDICARE: ELGIN PRIMARY CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04528167	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1104041136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELGIN PRIMARY CARE

Provider Business Mailing Address
First Line	:	1276 W SPRING ST
Second Line	:
City	:	SOUTH ELGIN
State	:	IL
Zip	:	60177-3304
Country	:	US
Telephone Number	:	847-468-1206
Fax Number	:

Provider Business Practice Location Address
First Line	:	1276 W SPRING ST
Second Line	:
City	:	SOUTH ELGIN
State	:	IL
Zip	:	60177-3304
Country	:	US
Telephone Number	:	847-468-1206
Fax Number	:

Authorized Official
Title or Position	:	BILLING
Name	:	TRACY A RADY
Credential	:
Telephone Number	:	847-429-0571

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	08/22/2020

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