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

Table of content: (NPI 1164530713)

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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