| Performance Medical Clinic Llc | |
|
5036 N Illinois St Suite 1 Fairview Heights IL 62208 | |
| (618) 671-6800 | |
| (619) 671-6604 |
| Full Name | Performance Medical Clinic Llc |
|---|---|
| Speciality | Internal Medicine |
| Location | 5036 N Illinois St, Fairview Heights, Illinois |
| Authorized Official Name and Position | Michael Thomas Ambrose (OWNER/CEO) |
| Authorized Official Contact | 6184209360 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Performance Medical Clinic Llc 5036 N Illinois St Ste 1 Fairview Heights IL 62208-3411 Ph: (618) 671-6800 | Performance Medical Clinic Llc 5036 N Illinois St Suite 1 Fairview Heights IL 62208 Ph: (618) 671-6800 |
| NPI Number | 1255746715 |
|---|---|
| Provider Enumeration Date | 06/24/2014 |
| Last Update Date | 07/18/2018 |
| Medicare PECOS PAC ID | 7416173638 |
|---|---|
| Medicare Enrollment ID | O20140724001285 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255746715 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| Provider Name | Michael Ambrose |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1538398680 PECOS PAC ID: 2961489034 Enrollment ID: I20040707000149 |
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