Basic Information
| Provider Information | |||||||||
| NPI: | 1114166295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC HEART SURGERY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6547 N AVONDALE AVE | ||||||||
| Address2: | #001 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606311573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737751622 | ||||||||
| FaxNumber: | 7737751693 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 N WALNUT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WOOD DALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601911566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308600035 | ||||||||
| FaxNumber: | 6308605262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2009 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | HENNEIN | ||||||||
| AuthorizedOfficialFirstName: | HANI | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6308600035 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 036-099190 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.