1407073182 NPI number — CARDIOSOM, LLC

Table of content: (NPI 1407073182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407073182 NPI number — CARDIOSOM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIOSOM, LLC
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:
CARDIOSOM OF PEORIA
Provider Other Organization Name Type Code:
3
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:
1407073182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 W CARMEL DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-2996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-868-1920
Provider Business Mailing Address Fax Number:
800-868-1908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5405 N KNOXVILLE AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-5016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-589-1180
Provider Business Practice Location Address Fax Number:
309-589-1189
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREISL
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
COOPRESIDENT
Authorized Official Telephone Number:
317-706-1080

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , 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)





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