Provider Demographics
NPI:1154556843
Name:PRIMARY CARE SPECIALISTS, LLC
Entity type:Organization
Organization Name:PRIMARY CARE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRIVALLI
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-579-6778
Mailing Address - Street 1:2 AIRLINE DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 AIRLINE DR
Practice Address - Street 2:SUITE 500
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3433
Practice Address - Country:US
Practice Address - Phone:636-579-6778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-25
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121501207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2503Medicare PIN