Provider Demographics
NPI:1215138219
Name:TINLEY PRIMARY CARE, LTD
Entity type:Organization
Organization Name:TINLEY PRIMARY CARE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBILIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-429-1200
Mailing Address - Street 1:17148 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3370
Mailing Address - Country:US
Mailing Address - Phone:708-429-1200
Mailing Address - Fax:708-429-4845
Practice Address - Street 1:17148 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3370
Practice Address - Country:US
Practice Address - Phone:708-429-1200
Practice Address - Fax:708-429-4845
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TINLEY MEDICAL ASSOC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL625240Medicare PIN
ILDA5367Medicare PIN