Provider Demographics
NPI:1164508933
Name:PEDIATRIC CARDIOLOGY ASSOCIATES OF NORTHERN ILLINOIS SC
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY ASSOCIATES OF NORTHERN ILLINOIS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUYOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-227-5600
Mailing Address - Street 1:5701 STRATHMOOR DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5182
Mailing Address - Country:US
Mailing Address - Phone:815-227-5600
Mailing Address - Fax:815-227-9242
Practice Address - Street 1:5701 STRATHMOOR DR
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5182
Practice Address - Country:US
Practice Address - Phone:815-227-5600
Practice Address - Fax:815-227-9242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042616967173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE98074Medicare UPIN
ILA02085Medicare UPIN
ILD16406Medicare UPIN