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General NPI Number Information
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NPI Number | 1306914791
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Entity Type | Organization
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Legal Business Name | PREVENTIVE CARDIOVASCULAR SERVICES SC
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 09/18/2009
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Provider Practice Location Address
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Address Line | 356 W SUPERIOR ST FL 2
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City | CHICAGO
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State | IL
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Zip | 60654-3416
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Country | US
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Telephone | 312-932-0300
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 187
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City | TINLEY PARK
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State | IL
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Zip | 60477-0187
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Country | US
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Telephone | 708-479-6522
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Fax | 708-479-6597
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALAN JACKSON
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Credential | MD
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Telephone | 708-479-6522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 036081595
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License Number State | IL
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