1164530713 NPI number — CONSULTANTS IN CARDIOVASCULAR MEDICINE, S. C.

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 1164530713 NPI number — CONSULTANTS IN CARDIOVASCULAR MEDICINE, S. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONSULTANTS IN CARDIOVASCULAR MEDICINE, 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:
1164530713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
675 W NORTH AVENUE
Provider Second Line Business Mailing Address:
SUITE-210
Provider Business Mailing Address City Name:
MELROSE PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60160-1634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-838-1448
Provider Business Mailing Address Fax Number:
708-344-0508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
675 W NORTH AVENUE
Provider Second Line Business Practice Location Address:
SUITE-210
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60160-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-838-1448
Provider Business Practice Location Address Fax Number:
708-344-0508
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHANES
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-838-1448

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  36-064782 , 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: 479-70-6233001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036-064782 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 961280 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CC1592 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 478-94-8068001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036-104771 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 216577 . This is a "MEDICARE LOCALITY 015 GROUP PTAN NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 31602469 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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