1205097201 NPI number — PRI-MED MEDICAL CENTER S C

Table of content: (NPI 1205097201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205097201 NPI number — PRI-MED MEDICAL CENTER S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRI-MED MEDICAL CENTER S C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205097201
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 527
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALOS PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60464-0527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-226-4961
Provider Business Mailing Address Fax Number:
708-364-9301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10715 W 159TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLAND PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60467-4531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-226-4961
Provider Business Practice Location Address Fax Number:
708-364-9301
Provider Enumeration Date:
06/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
SHIRIN
Authorized Official Middle Name:
ARIF
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-226-4961

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036085803 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036085803 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11023950 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".