1811324064 NPI number — METRO PRIMARY CARE ASSOCIATES LLC

Table of content: (NPI 1811324064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811324064 NPI number — METRO PRIMARY CARE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO PRIMARY CARE ASSOCIATES LLC
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:
6
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:
1811324064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 MCCLINTOCK DRIVE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-0844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-220-6432
Provider Business Mailing Address Fax Number:
630-654-4253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13755 S. CICERO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60445-1824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-972-7642
Provider Business Practice Location Address Fax Number:
708-925-9179
Provider Enumeration Date:
10/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ROCK
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CLINICAL OPERATIONS
Authorized Official Telephone Number:
708-972-7636

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F100106060 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com