Healthcare Provider Details

I. General information

NPI: 1497704514
Provider Name (Legal Business Name): CARDIOSPECIALISTS GROUP, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 GETTLER ST SUITE 122
DYER IN
46311-2380
US

IV. Provider business mailing address

39649 TREASURY CTR
CHICAGO IL
60694-9000
US

V. Phone/Fax

Practice location:
  • Phone: 219-319-0300
  • Fax: 219-440-7475
Mailing address:
  • Phone: 219-319-0300
  • Fax: 219-440-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRAD L SUPRENANT
Title or Position: PRESIDENT/MANAGING PARTNER
Credential: DO
Phone: 219-319-0300