Provider Demographics
NPI:1407073182
Name:CARDIOSOM, LLC
Entity Type:Organization
Organization Name:CARDIOSOM, LLC
Other - Org Name:CARDIOSOM OF PEORIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COOPRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREISL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-706-1080
Mailing Address - Street 1:615 W CARMEL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2996
Mailing Address - Country:US
Mailing Address - Phone:800-868-1920
Mailing Address - Fax:800-868-1908
Practice Address - Street 1:5405 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5016
Practice Address - Country:US
Practice Address - Phone:309-589-1180
Practice Address - Fax:309-589-1189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5348030013Medicare NSC