Healthcare Provider Details

I. General information

NPI: 1194844050
Provider Name (Legal Business Name): CARDIOSPECIALISTS GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20303 CRAWFORD AVE SUITE LL3
OLYMPIA FIELDS IL
60461-1073
US

IV. Provider business mailing address

20303 CRAWFORD AVE SUITE LL3
OLYMPIA FIELDS IL
60461-1073
US

V. Phone/Fax

Practice location:
  • Phone: 708-748-9800
  • Fax: 708-748-9807
Mailing address:
  • Phone: 708-748-9800
  • Fax: 708-748-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036071427
License Number StateIL

VIII. Authorized Official

Name: DR. BRAD L SUPRENANT
Title or Position: PRESIDENT
Credential: D.O.
Phone: 708-748-9800