NPIMap

Organization Active NPI

Primecare Community Health, Inc.

Doing business as PrimeCare Hamlin

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1356622500
Registry record updated Oct 26, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PRIMECARE COMMUNITY HEALTH, INC.
Doing business as
PrimeCare Hamlin
Practice address
1920 N Hamlin Ave
Chicago, IL 60647-3411
Phone
(773) 772-7202
Fax
(773) 772-7244
NPI assigned
Sep 1, 2011
Last updated
Oct 26, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 26, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Joseph Moldovan
Title
Chief Executive Officer
Phone
(312) 491-5034

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1920 N Hamlin Ave
Chicago, IL 60647-3411

Mailing address

2232 N Clybourn Ave FL 3
Chicago, IL 60614-3193
Phone (312) 633-5841

Other names 1

  • PrimeCare Hamlin Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040227000011 IL Part B Supplier - Clinic/Group Practice 6204722077 Receives reassigned benefits from 89 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Chicago, IL
O20121207000000 IL Part A Provider - Federally Qualified Health Center (FQHC) 6204722077 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356622500. Details of each certification follow.

Federally qualified health center certification: CCN 141182

Legal name
PRIMECARE COMMUNITY HEALTH, INC.
Doing business as
PRIMECARE NORTHWEST
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 18, 2012
Last certification
Dec 18, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 21, 1992 in IL
Enrollment address
1920 N Hamlin Ave
Chicago, IL 60647-3411

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 8

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D1105693Primecare Hamlin1920 N Hamlin, Room 101, Chicago, IL 60647Provider-performed microscopySep 27, 2027

National Provider Directory

National Provider Directory

Locations

1127 N Oakley Blvd
Fl 2
Chicago, IL 60622
Phone (312) 633-5841

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Gary Kenzer Individual Corporate DirectorBoard Member Jul 1, 2021
Robert Dahl Individual Corporate DirectorBoard Member Jul 1, 2021
Jean Schwab Individual Corporate DirectorBoard Member Jul 1, 2021
Lynn Hopkins Individual Corporate OfficerCeo Jul 1, 2021
Jose Silva Individual Corporate DirectorBoard Member Jul 1, 2021
Sonia Talavera Individual Corporate DirectorBoard Member Jul 1, 2021
Edward McDermott Individual Corporate DirectorBoard Member Dec 1, 2021
Randall Palmer Individual Corporate DirectorBoard Member Jul 1, 2021
Rosita de la Rosa Individual Corporate DirectorBoard Member Jul 1, 2021
Cheryl Reese Individual Corporate DirectorBoard Member Jul 1, 2021
Benjamin Alonzo Individual Corporate DirectorBoard Member Jul 1, 2021
Luis Reyes Individual Corporate DirectorBoard Member Jul 1, 2021
Michael Holtrop Individual Corporate OfficerCfo Dec 1, 2021
W-2 Managing EmployeeCfo Dec 1, 2021
Robert J Cech Individual Corporate DirectorBoard Member Jul 1, 2021

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1314835200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1508976000000",
    "number": "1356622500",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2232 N CLYBOURN AVE FL 3",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606143193",
            "telephone_number": "312-633-5841",
            "fax_number": "773-269-5500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1920 N HAMLIN AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606473411",
            "telephone_number": "773-772-7202",
            "fax_number": "773-772-7244"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMECARE COMMUNITY HEALTH, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-09-01",
        "last_updated": "2017-10-26",
        "status": "A",
        "authorized_official_last_name": "MOLDOVAN",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "312-491-5034"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PrimeCare Hamlin",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.