MEDICARE: PRIME MEDICAL CLINIC S.C.

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	207QA0505X	Adult Medicine Physician	036135325	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659815074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME MEDICAL CLINIC S.C.

Provider Business Mailing Address
First Line	:	333 W DUNDEE RD
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-3545
Country	:	US
Telephone Number	:	847-243-0355
Fax Number	:

Provider Business Practice Location Address
First Line	:	3633 W LAKE AVE STE 307
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60026-5803
Country	:	US
Telephone Number	:	847-626-8722
Fax Number	:	847-316-9502

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	DR. KONSTANTINS KOCIASVILI
Credential	:	MD
Telephone Number	:	773-507-7434

Provider Enumeration Date	:	12/05/2016
Last Update Date	:	01/13/2023

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