Provider Demographics
NPI:1962459263
Name:PRIMECARECOMMUNITY HEALTH, INC
Entity type:Organization
Organization Name:PRIMECARECOMMUNITY HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-633-5841
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE #406
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:312-633-5841
Mailing Address - Fax:312-491-5020
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE #406
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:312-633-5841
Practice Address - Fax:312-491-5020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ68704Medicare UPIN