Provider Demographics
NPI:1386818557
Name:DOR HEART & VASCULAR, PC
Entity Type:Organization
Organization Name:DOR HEART & VASCULAR, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-926-8320
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:20 TOWER CT
Practice Address - Street 2:SUITE F
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5711
Practice Address - Country:US
Practice Address - Phone:847-662-9420
Practice Address - Fax:847-662-9457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101942207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101942Medicaid
IL1982718409OtherNPI TYPE 1
IL1982718409OtherNPI TYPE 1