1962417485 NPI number — CARDIAC THORACIC & ENDOVASCULAR THERAPIES, S.C.

Table of content: (NPI 1962417485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962417485 NPI number — CARDIAC THORACIC & ENDOVASCULAR THERAPIES, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIAC THORACIC & ENDOVASCULAR THERAPIES, S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962417485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2420 W NEBRASKA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61604-3112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-680-5000
Provider Business Mailing Address Fax Number:
309-680-1002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2420 W NEBRASKA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61604-3112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-680-5000
Provider Business Practice Location Address Fax Number:
309-680-1002
Provider Enumeration Date:
07/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
BERTRAM
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
309-680-8666

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036099138 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7232062 . This is a "BLUE SHIELD PROVIDER NO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00059260 . This is a "RETIRED RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DS6728 . This is a "RETIRED RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".