1114018439 NPI number — ILLINOIS CARDIAC SURGERY ASSOCIATES SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114018439 NPI number — ILLINOIS CARDIAC SURGERY ASSOCIATES SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS CARDIAC SURGERY ASSOCIATES SC
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:
1114018439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 NE GLEN OAK
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61603-3167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-674-2002
Provider Business Mailing Address Fax Number:
309-624-9898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 NE GLEN OAK
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61603-3167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-674-2002
Provider Business Practice Location Address Fax Number:
309-624-9898
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GEISS
Authorized Official First Name:
DALE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-674-2002

Provider Taxonomy Codes

  • 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: 07215075 . This is a "BLUE SHEILD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com