PRIMECARE FULLERTON
Complete NPI Record 1992851067
Clinic/Center - Federally Qualified Health Center (FQHC) in Chicago, IL
NPI Status: Active since January 25, 2007
Contact Information
3924 W FULLERTON AVE
CHICAGO, IL
ZIP 60647
Phone: (773) 276-2229
Fax: (773) 276-2190
Complete NPI Dataset
This directory record outlines the complete schema field listings, logged data values, and structural definitions for PRIMECARE FULLERTON (NPI: 1992851067), practicing as a certified clinic/center specialist with primary operations located in Chicago, IL. The dataset listed below details the current information logged inside the National Plan and Provider Enumeration System (NPPES) registry database for this specific individual assignment. Please use the integrated filtering tools directly below to separate properties by functional clinical categories, perform live keyword lookups, or jump immediately to a single tracking attribute line item.
Registry File Document Utilities
- NPI: 1992851067
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: UNAVAIL
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: PRIMECARE COMMUNITY HEALTH, INC.
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider Other Organization Name: PRIMECARE FULLERTON
- Other name by which the organization provider is or has been known.
- Provider Other Organization Name Type Code: 3
- Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
- Provider First Line Business Mailing Address: 1431 N. WESTERN AVE.
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Second Line Business Mailing Address: SUITE #401
- The second line mailing address of the provider being identified. This data element may contain the same information as "Provider second line location address".
- Provider Business Mailing Address City Name: CHICAGO
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: IL
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 606221797
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 3126335841
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 3124915485
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 3924 W FULLERTON AVE
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: CHICAGO
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: IL
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 606472228
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 7732762229
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 7732762190
- The fax number associated with the location address of the provider being identified.
- Authorized Official Last Name: MOLDOVAN
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: JOSEPH
- The first name of the authorized official.
- Authorized Official Title or Position: CHIEF FINANCIAL OFFICER
- The title or position of the authorized official.
- Authorized Official Telephone Number: 3124915034
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 207Q00000X
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 1: N
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 2: 261QF0400X
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 2: Y
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: =========010
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 05
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: IL
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Is Organization Subpart: N
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Healthcare Provider Taxonomy Group 1: 193200000X MULTI-SPECIALTY GROUP
- Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.
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