Healthcare Provider Details

I. General information

NPI: 1457315624
Provider Name (Legal Business Name): SEAN P TIERNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11560 S KEDZIE AVE STE 100
MERRIONETTE PARK IL
60803-4517
US

IV. Provider business mailing address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

V. Phone/Fax

Practice location:
  • Phone: 708-824-1114
  • Fax: 708-824-9341
Mailing address:
  • Phone: 708-478-3600
  • Fax: 708-478-3552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036096266
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036096266
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: