Healthcare Provider Details

I. General information

NPI: 1447520291
Provider Name (Legal Business Name): ADVANCED CENTER FOR CARDIOTHORACIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N MICHIGAN ST 503
SOUTH BEND IN
46601-1067
US

IV. Provider business mailing address

707 N MICHIGAN ST 503
SOUTH BEND IN
46601-1067
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-6500
  • Fax: 574-647-6518
Mailing address:
  • Phone: 574-647-6500
  • Fax: 574-647-6518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number01034778A
License Number StateIN

VIII. Authorized Official

Name: MR. JAMES PATRICK KELLY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 574-647-6500