MEDICARE: CARDIOVASCULAR ASSOCIATES, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	42007401	IL
2	207RC0001X	Clinical Cardiac Electrophysiology Physician	42007401	IL
3	207RC0000X	Cardiovascular Disease Physician	42007401	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1619483	OTHER	IL	BCBS
2	4478598	OTHER	IL	AETNA
3	1146003	OTHER	IL	UNITED HEALTHCARE
4	343940	OTHER	IL	LOCALITY 16
5	0503174	OTHER	IL	CIGNA

General Provider Information

NPI Number	:	1740231505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOVASCULAR ASSOCIATES, S.C.

Provider Business Mailing Address
First Line	:	900 S FRONTAGE RD
Second Line	:	SUITE 325
City	:	WOODRIDGE
State	:	IL
Zip	:	60517-4903
Country	:	US
Telephone Number	:	847-981-3680
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 BIESTERFIELD RD STE G01
Second Line	:	WIMMER BUILDING
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3372
Country	:	US
Telephone Number	:	847-981-3680
Fax Number	:	847-956-5122

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JACK R CHAMBERLIN
Credential	:	M.D.
Telephone Number	:	847-981-3680

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	02/05/2010

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