Provider Demographics
NPI:1144761404
Name:SANDRA ILLUM MD PLLC
Entity Type:Organization
Organization Name:SANDRA ILLUM MD PLLC
Other - Org Name:ADVANCED HEART AND VASCULAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CARDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNIKA
Authorized Official - Middle Name:SANDRA
Authorized Official - Last Name:ILLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-377-7576
Mailing Address - Street 1:17101 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1331
Mailing Address - Country:US
Mailing Address - Phone:214-377-7576
Mailing Address - Fax:
Practice Address - Street 1:17101 PRESTON RD STE 190S
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1331
Practice Address - Country:US
Practice Address - Phone:214-500-1689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1086207RC0000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U3Z7OtherBCBS