Provider Demographics
NPI:1902821887
Name:ADVANCED HEART LIPID CLINIC
Entity Type:Organization
Organization Name:ADVANCED HEART LIPID CLINIC
Other - Org Name:ADVANCED HEART AND HEALTHCARE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ENAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-960-1844
Mailing Address - Street 1:4121 FAIRVIEW AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2264
Mailing Address - Country:US
Mailing Address - Phone:630-960-1844
Mailing Address - Fax:630-852-0244
Practice Address - Street 1:4121 FAIRVIEW AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2264
Practice Address - Country:US
Practice Address - Phone:630-960-1844
Practice Address - Fax:630-852-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042003489OtherCORPORATION LICENSE