Healthcare Provider Details

I. General information

NPI: 1982845566
Provider Name (Legal Business Name): NORTHWEST CARDIOLOGY ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W NORTHWEST HWY
BARRINGTON IL
60010-3049
US

IV. Provider business mailing address

PO BOX 3730
BARRINGTON IL
60011-3730
US

V. Phone/Fax

Practice location:
  • Phone: 847-382-4600
  • Fax: 847-382-1771
Mailing address:
  • Phone: 847-382-4600
  • Fax: 847-382-1771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036090812
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036090812
License Number StateIL

VIII. Authorized Official

Name: MICHAEL N FORTSAS
Title or Position: PRESIDENT
Credential: MD
Phone: 847-382-4600