Provider Demographics
NPI:1821398439
Name:TALLGRASS CARDIOLOGY SERVICES SC
Entity Type:Organization
Organization Name:TALLGRASS CARDIOLOGY SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERSHEL
Authorized Official - Middle Name:LISTON
Authorized Official - Last Name:WIX
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:815-937-9370
Mailing Address - Street 1:475 BROWN BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2325
Mailing Address - Country:US
Mailing Address - Phone:815-937-9370
Mailing Address - Fax:815-937-2700
Practice Address - Street 1:475 BROWN BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2325
Practice Address - Country:US
Practice Address - Phone:815-937-9370
Practice Address - Fax:815-937-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051497207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty