| Prime Medical Clinic S.c. | |
|
3633 W Lake Ave Ste 307 Glenview IL 60026-5803 | |
| (847) 626-8722 | |
| (847) 316-9502 |
| Full Name | Prime Medical Clinic S.c. |
|---|---|
| Speciality | Family Medicine |
| Location | 3633 W Lake Ave Ste 307, Glenview, Illinois |
| Authorized Official Name and Position | Konstantins Kociasvili (MEDICAL DOCTOR) |
| Authorized Official Contact | 7735077434 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Prime Medical Clinic S.c. 333 W Dundee Rd Buffalo Grove IL 60089-3545 Ph: (847) 243-0355 | Prime Medical Clinic S.c. 3633 W Lake Ave Ste 307 Glenview IL 60026-5803 Ph: (847) 626-8722 |
| NPI Number | 1659815074 |
|---|---|
| Provider Enumeration Date | 12/05/2016 |
| Last Update Date | 01/13/2023 |
| Medicare PECOS PAC ID | 1355622176 |
|---|---|
| Medicare Enrollment ID | O20170109003261 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659815074 | NPI | - | NPPES |
| 036135325 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207QA0505X | Family Medicine - Adult Medicine | 036135325 (Illinois) | Primary |
| Provider Name | Konstantins Kociasvili |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1588854848 PECOS PAC ID: 4880874544 Enrollment ID: I20141117001133 |
| Provider Name | Nelli A Ban |
|---|---|
| Provider Type | Practitioner - Physical Therapist In Private Practice |
| Provider Identifiers | NPI Number: 1710434832 PECOS PAC ID: 6305126228 Enrollment ID: I20161212002388 |
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