1356590178 NPI number — ADVANCED HEART CARE

Table of content: (NPI 1356590178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356590178 NPI number — ADVANCED HEART CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED HEART CARE
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:
1356590178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62223-0140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-222-8900
Provider Business Mailing Address Fax Number:
618-222-8950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 MEMORIAL DR
Provider Second Line Business Practice Location Address:
W3
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-5366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-222-8900
Provider Business Practice Location Address Fax Number:
618-222-8950
Provider Enumeration Date:
09/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ALMOUSALLI
Authorized Official First Name:
OMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-222-8900

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  036097388 , 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: 0360973885 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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