MEDICARE: PRIME CARE MEDICAL CENTER SC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207Q00000X	Family Medicine Physician	IL
2	207Q00000X	Family Medicine Physician	IL
3	207R00000X	Internal Medicine Physician	IL
4	207Q00000X	Family Medicine Physician	IL

General Provider Information

NPI Number	:	1427228642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME CARE MEDICAL CENTER SC

Provider Business Mailing Address
First Line	:	99 BOULDER HILL PASS
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1911
Country	:	US
Telephone Number	:	630-897-2848
Fax Number	:	630-897-4498

Provider Business Practice Location Address
First Line	:	99 BOULDER HILL PASS
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1911
Country	:	US
Telephone Number	:	630-897-2848
Fax Number	:	630-897-4498

Authorized Official
Title or Position	:	PRES OWNER
Name	:	MR. NICHOLAS GEORGE TZANETAKOS
Credential	:	MD
Telephone Number	:	630-897-2848

Provider Enumeration Date	:	03/04/2008
Last Update Date	:	03/04/2008

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