Provider Demographics
NPI:1447454657
Name:ADVANCED CARDIOVASCULAR SERVICES
Entity type:Organization
Organization Name:ADVANCED CARDIOVASCULAR SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-460-5000
Mailing Address - Street 1:PO BOX 882
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-0882
Mailing Address - Country:US
Mailing Address - Phone:815-936-3200
Mailing Address - Fax:815-936-3203
Practice Address - Street 1:455 W. COURT ST.
Practice Address - Street 2:SUITE 202
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60441
Practice Address - Country:US
Practice Address - Phone:805-936-3200
Practice Address - Fax:815-936-3203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004632018OtherBLUE CROSS
IL036082059Medicaid
ILP00059541OtherRAILROAD MEDICARE
IL036082059Medicaid
IL203483Medicare PIN