Provider Demographics
NPI:1952467375
Name:INTRA-HEARTS SERVICE CORPORATION
Entity Type:Organization
Organization Name:INTRA-HEARTS SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-206-0305
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-0947
Mailing Address - Country:US
Mailing Address - Phone:708-206-0305
Mailing Address - Fax:708-206-0300
Practice Address - Street 1:5320 159TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3329
Practice Address - Country:US
Practice Address - Phone:708-206-0305
Practice Address - Fax:708-206-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065418207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E29405Medicare UPIN