Healthcare Provider Details

I. General information

NPI: 1457438848
Provider Name (Legal Business Name): ILLIANA CARDIOVASCULAR CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 GETTLER ST STE 455
DYER IN
46311
US

IV. Provider business mailing address

2150 GETTLER ST STE 455
DYER IN
46311-2381
US

V. Phone/Fax

Practice location:
  • Phone: 219-864-1100
  • Fax: 219-864-1118
Mailing address:
  • Phone: 219-864-1100
  • Fax: 219-864-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01029938
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036056772
License Number StateIL

VIII. Authorized Official

Name: JAGDISH PATEL
Title or Position: PRESIDENT
Credential: MD
Phone: 219-398-9184