Provider Demographics
NPI:1205863578
Name:PEDIATRIC CARDIOLOGY ASSOCIATES SC
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-655-3453
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3105
Mailing Address - Country:US
Mailing Address - Phone:309-655-3453
Mailing Address - Fax:309-655-3410
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-655-3453
Practice Address - Fax:309-655-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL456350Medicare ID - Type Unspecified