MEDICARE: PRIMECARE COMMUNITY HEALTH, INC.

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	207Q00000X	Family Medicine Physician
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1356622500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMECARE COMMUNITY HEALTH, INC.

Provider Business Mailing Address
First Line	:	2232 N CLYBOURN AVE FL 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-3193
Country	:	US
Telephone Number	:	312-633-5841
Fax Number	:	773-269-5500

Provider Business Practice Location Address
First Line	:	1920 N HAMLIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3411
Country	:	US
Telephone Number	:	773-772-7202
Fax Number	:	773-772-7244

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	JOSEPH MOLDOVAN
Credential	:
Telephone Number	:	312-491-5034

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	10/26/2017

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