Provider Demographics
NPI:1447732961
Name:PRIMEHEALTH OF OHIO LLC
Entity type:Organization
Organization Name:PRIMEHEALTH OF OHIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:B
Authorized Official - Last Name:DEVAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-632-5613
Mailing Address - Street 1:2100 E LAKE COOK RD STE 1000
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 S 3RD ST STE 210
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4206
Practice Address - Country:US
Practice Address - Phone:844-882-3127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0180374Medicaid