Healthcare Provider Details

I. General information

NPI: 1720023179
Provider Name (Legal Business Name): HEARTCARE MIDWEST , LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 N KNOXVILLE AVENUE
PEORIA IL
61614-5016
US

IV. Provider business mailing address

5405 N KNOXVILLE AVENUE
PEORIA IL
61614-5016
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-4410
  • Fax: 309-589-2830
Mailing address:
  • Phone: 309-691-4410
  • Fax: 309-589-2830

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 Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MUHAMMAD FAYAZ MALIK
Title or Position: CHIEF MEDIAL OFFICER
Credential: MD
Phone: 309-691-4410