Provider Demographics
NPI:1962450734
Name:ILLINOIS CARDIOVASCULAR & THORACIC SURGERY, LTD
Entity Type:Organization
Organization Name:ILLINOIS CARDIOVASCULAR & THORACIC SURGERY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIREF OPERATIONS OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-662-5506
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7906
Mailing Address - Country:US
Mailing Address - Phone:309-662-5506
Mailing Address - Fax:309-662-5443
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7906
Practice Address - Country:US
Practice Address - Phone:309-662-5506
Practice Address - Fax:309-662-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05732036OtherBLUE SHIELD GROUP NUMBER
IL204815Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL204814Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
CK7113Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP