Healthcare Provider Details

I. General information

NPI: 1962450734
Provider Name (Legal Business Name): ILLINOIS CARDIOVASCULAR & THORACIC SURGERY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR SUITE 210
BLOOMINGTON IL
61701-7906
US

IV. Provider business mailing address

1505 EASTLAND DR SUITE 210
BLOOMINGTON IL
61701-7906
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-5506
  • Fax: 309-662-5443
Mailing address:
  • Phone: 309-662-5506
  • Fax: 309-662-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GLEN B SMITH
Title or Position: CHIREF OPERATIONS OFFICER
Credential: M.D.
Phone: 309-662-5506