Basic Information
| Provider Information | |||||||||
| NPI: | 1871574863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SUBURBAN CARDIOLOGY LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17901 GOVERNORS HWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HOMEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604301144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087990180 | ||||||||
| FaxNumber: | 7087993839 | ||||||||
| Practice Location | |||||||||
| Address1: | 17901 GOVERNORS HWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HOMEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604301144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087990180 | ||||||||
| FaxNumber: | 7087993839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 04/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | HAMID | ||||||||
| AuthorizedOfficialFirstName: | IMTIAZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7087990180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | CA0145 | 01 | IL | RAILROAD MEDICARE | OTHER | CB0037 | 01 | IL | RAILROAD MEDICARE | OTHER | CB1134 | 01 | IL | RR MEDICARE | OTHER |