Provider Demographics
NPI:1700842390
Name:NORTHERN ILLINOIS CARDIOVASCULAR & THORACIC SPECIALISTS,LLC
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS CARDIOVASCULAR & THORACIC SPECIALISTS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOWERSOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:847-788-1553
Mailing Address - Street 1:1100 W CENTRAL RD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2402
Mailing Address - Country:US
Mailing Address - Phone:847-788-1553
Mailing Address - Fax:847-788-1585
Practice Address - Street 1:880 W CENTRAL RD
Practice Address - Street 2:SUITE 5300
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2355
Practice Address - Country:US
Practice Address - Phone:847-788-1553
Practice Address - Fax:847-788-1585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH13361Medicare UPIN
ILC43226Medicare UPIN
IL204238Medicare ID - Type UnspecifiedNORTHERN IL CARDIOVASCULA
IL204241Medicare ID - Type UnspecifiedNORTHERN IL CARDIOVASCULA
ILI26996Medicare UPIN
ILE18563Medicare UPIN