Healthcare Provider Details

I. General information

NPI: 1720179831
Provider Name (Legal Business Name): ASSOCIATED CARDIOVASCULAR PHYSICIANS, S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 S HARLEM AVE STE 112
PALOS HEIGHTS IL
60463-1477
US

IV. Provider business mailing address

12400 S HARLEM AVE STE 112
PALOS HEIGHTS IL
60463-1477
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-7650
  • Fax: 708-923-7655
Mailing address:
  • Phone: 708-923-7650
  • Fax: 708-923-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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 TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICK PORONSKY
Title or Position: OFFICE MANAGER
Credential:
Phone: 708-923-7650