Provider Demographics
NPI:1225146483
Name:CARDIO-MEDICINE SC
Entity Type:Organization
Organization Name:CARDIO-MEDICINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:S
Authorized Official - Last Name:JANICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-422-8282
Mailing Address - Street 1:9210 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0092
Mailing Address - Country:US
Mailing Address - Phone:708-422-8282
Mailing Address - Fax:708-422-9111
Practice Address - Street 1:9830 RIDGELAND AVE
Practice Address - Street 2:STE 5
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2667
Practice Address - Country:US
Practice Address - Phone:708-422-8282
Practice Address - Fax:708-422-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044355207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE14048Medicare UPIN
IL210651Medicare PIN