Provider Demographics
NPI:1225528979
Name:THORACIC SURGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:THORACIC SURGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-346-4065
Mailing Address - Street 1:10604 SOUTHWEST HIGHWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415
Mailing Address - Country:US
Mailing Address - Phone:708-346-4065
Mailing Address - Fax:708-423-5799
Practice Address - Street 1:10604 SOUTHWEST HIGHWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415
Practice Address - Country:US
Practice Address - Phone:708-346-4065
Practice Address - Fax:708-423-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPENDING208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGOtherIL LICENSE