Provider Demographics
NPI:1588972616
Name:PREMIER MEDICAL CARE ADDISON, LTD
Entity type:Organization
Organization Name:PREMIER MEDICAL CARE ADDISON, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANATOLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOROVITS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-705-1630
Mailing Address - Street 1:1415 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1870
Mailing Address - Country:US
Mailing Address - Phone:630-705-1630
Mailing Address - Fax:630-705-1692
Practice Address - Street 1:1415 W LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1870
Practice Address - Country:US
Practice Address - Phone:630-705-1630
Practice Address - Fax:630-705-1692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113828208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty