Healthcare Provider Details

I. General information

NPI: 1366890782
Provider Name (Legal Business Name): PREMIER VASCULAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11560 S KEDZIE AVE
MERRIONETTE PARK IL
60803-4517
US

IV. Provider business mailing address

11560 S KEDZIE AVE
MERRIONETTE PARK IL
60803-4517
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-3600
  • Fax: 708-478-3553
Mailing address:
  • Phone: 708-972-7525
  • Fax: 708-972-7526

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 Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK BERLIN
Title or Position: COO
Credential:
Phone: 708-478-3600