NPIMap

Organization Active NPI

Primecare Community Health, Inc.

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1992851067
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.
Practice address
3924 W Fullerton Ave
Chicago, IL 60647-2228
Phone
(773) 276-2229
Fax
(773) 276-2190
NPI assigned
Jan 25, 2007
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
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

3924 W Fullerton Ave
Chicago, IL 60647-2228

Mailing address

1431 N. Western Ave.
Suite #401
Chicago, IL 60622-1797
Phone (312) 633-5841

Other names 1

  • PrimeCare Fullerton 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
O20070111000413 IL Part A Provider - Federally Qualified Health Center (FQHC) 6204722077 Practice locations: Chicago, IL

Federally qualified health center certification: CCN 141985

Legal name
PRIMECARE COMMUNITY HEALTH, INC.
Doing business as
PRIMECARE FULLERTON
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
3924 W. Fullerton
Chicago, IL 60647-2228

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
14D0872741Primecare Fullerton3924 W Fullerton, Chicago, IL 60647Provider-performed microscopyJun 30, 2027

National Provider Directory

National Provider Directory

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 Director Jul 1, 2021
Robert Dahl Individual Corporate Director Jul 1, 2021
Jean Schwab Individual Corporate Director Jul 1, 2021
Lynn Hopkins Individual Corporate OfficerCeo Jul 1, 2021
Jose Silva Individual Corporate Director Jul 1, 2021
Sonia Talavera Individual Corporate Director Jul 1, 2021
Edward McDermott Individual Corporate Director Jul 1, 2021
Randall Palmer Individual Corporate Director Jul 1, 2021
Rosita de la Rosa Individual Corporate Director Jul 1, 2021
Cheryl Reese Individual Corporate Director Jul 1, 2021
Benjamin Alonzo Individual Corporate Director Jul 1, 2021
Luis Reyes Individual Corporate Director 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 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

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": "1992851067",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1431 N. WESTERN AVE.",
            "address_2": "SUITE #401",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606221797",
            "telephone_number": "312-633-5841",
            "fax_number": "312-491-5485"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3924 W FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606472228",
            "telephone_number": "773-276-2229",
            "fax_number": "773-276-2190"
        }
    ],
    "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": "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 Fullerton",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.