Healthcare Provider Details

I. General information

NPI: 1104238534
Provider Name (Legal Business Name): HEART CARE CENTERS OF ILLINOIS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13011 S 104TH AVE
PALOS PARK IL
60464-1506
US

IV. Provider business mailing address

13011 S 104TH AVE SUITE 100
PALOS PARK IL
60464-1506
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number207R00000X
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS GEDZUN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 708-478-3600