NPIMap

Organization Active NPI

Primecare Community Health, Inc.

Doing business as PrimeCare Northwest

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1730235870
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 Northwest
Practice address
1649 N Pulaski Rd
Chicago, IL 60639-5207
Phone
(773) 278-6868
Fax
(773) 278-6922
NPI assigned
Jan 25, 2007
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 Financial Officer
Phone
(312) 491-5034

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Family Medicine Physician 207Q00000X

Addresses

Primary practice location

1649 N Pulaski Rd
Chicago, IL 60639-5207

Mailing address

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

Other names 1

  • PrimeCare Northwest 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
O20070111000418 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 1730235870. Details of each certification follow.

Federally qualified health center certification: CCN 141986

Legal name
PRIMECARE COMMUNITY HEALTH, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 11, 2002
Last certification
Jan 11, 2002
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 21, 1992 in IL
Enrollment address
1649 N Pulaski Rd
Chicago, IL 60639-5207

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.

National Provider Directory

National Provider Directory

Locations

2211 N Elston Ave
Ste 301
Chicago, IL 60614

2232 N Clybourn Ave
Fl 3
Chicago, IL 60614
Phone (773) 377-5491

Ownership & related parties

All disclosed owners & managing parties 13

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 Jul 1, 2021
Randall Palmer Individual Corporate DirectorBoard Member Jul 1, 2021
Cheryl Reese Individual Corporate DirectorBoard Member Jul 1, 2021
Benjamin Alonzo Individual Corporate DirectorBoard Member Jan 1, 2015
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 Director Jul 1, 2021

Practitioners & affiliated clinicians

Practitioners 16

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.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1169683200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1508976000000",
    "number": "1730235870",
    "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": "1649 N PULASKI RD",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606395207",
            "telephone_number": "773-278-6868",
            "fax_number": "773-278-6922"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMECARE COMMUNITY HEALTH, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-25",
        "last_updated": "2017-10-26",
        "status": "A",
        "authorized_official_last_name": "MOLDOVAN",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "312-491-5034"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PrimeCare Northwest",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.