Provider Demographics
NPI:1356506307
Name:ANTONIO B. CRUZ M.D.S.C.
Entity Type:Organization
Organization Name:ANTONIO B. CRUZ M.D.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:B
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-289-7800
Mailing Address - Street 1:1601 TANGLEWOOD AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-3381
Mailing Address - Country:US
Mailing Address - Phone:630-289-7800
Mailing Address - Fax:630-289-9187
Practice Address - Street 1:1601 TANGLEWOOD AVE STE 106
Practice Address - Street 2:
Practice Address - City:HANOVER PARK
Practice Address - State:IL
Practice Address - Zip Code:60133-3381
Practice Address - Country:US
Practice Address - Phone:630-289-7800
Practice Address - Fax:630-289-9187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3640977261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036040977Medicaid
IL362175536OtherBCBS
454950Medicare PIN
IL362175536OtherBCBS