Provider Demographics
NPI:1194086157
Name:PC ASSOCIATES LLC
Entity type:Organization
Organization Name:PC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-257-4644
Mailing Address - Street 1:4500 MEMORIAL DR
Mailing Address - Street 2:MEDICAL AFFAIRS CREDENTIALING OFFICE
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5360
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:618-257-6946
Practice Address - Street 1:205 EAST BELLEVILLE STREET
Practice Address - Street 2:
Practice Address - City:OKAWVILLE
Practice Address - State:IL
Practice Address - Zip Code:62271
Practice Address - Country:US
Practice Address - Phone:618-327-8119
Practice Address - Fax:618-327-8141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PC ASSOCIATES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-06
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty