Healthcare Provider Details

I. General information

NPI: 1538355136
Provider Name (Legal Business Name): RUSH CENTER FOR CONGENITAL & STRUCTURAL HEART DISEASE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 11/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY 708 KELLOGG
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY 770 JONES
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6800
  • Fax:
Mailing address:
  • Phone: 312-942-6800
  • Fax: 312-942-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: BRIAN T SMITH
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 312-942-6909