Healthcare Provider Details

I. General information

NPI: 1093074155
Provider Name (Legal Business Name): COMPREHENSIVE CARDIOVASCULAR CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 NATIONS DR STE 111
GURNEE IL
60031-9175
US

IV. Provider business mailing address

PO BOX 2257
CHESTERTON IN
46304-0357
US

V. Phone/Fax

Practice location:
  • Phone: 224-656-5867
  • Fax: 219-926-3524
Mailing address:
  • Phone: 219-926-8320
  • Fax: 219-926-3524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036101942
License Number StateIL

VIII. Authorized Official

Name: TRACY FREEZE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 219-926-8320