Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207RI0011X | Internal Medicine | Interventional Cardiology | 036063633 | ILLINOIS | No |
| 2 | 207RC0000X | Internal Medicine | Cardiovascular Disease | 036063633 | ILLINOIS | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 344038 | OTHER | ILLINOIS | GHP ID# |
| 2 | 1609962992 | OTHER | ILLINOIS | TRICARE STANDARD ID# |
| 3 | 1609962992 | OTHER | ILLINOIS | UHC ID# |
| 4 | C47880 | MEDICARE UPIN | ILLINOIS | |
| 5 | 1609962992 | OTHER | ILLINOIS | TRICARE PRIME ID# |
| 6 | 4000254 | OTHER | ILLINOIS | AETNA ID# |
| 7 | 1609962992 | OTHER | ILLINOIS | BCBS OF IL ID# |
| 8 | 2092189 | OTHER | ILLINOIS | FIRST HEALTH ID# |
| 9 | 100603 | OTHER | ILLINOIS | HEALTHLINK ID# |
| 10 | 256717 | OTHER | ILLINOIS | WELLCARE ID# |
| 11 | R01749 | MEDICARE PIN | ILLINOIS | |
| 12 | 000000574721 | OTHER | ILLINOIS | BCBS OF MO ID# |
| 13 | 111197 | OTHER | ILLINOIS | HEALTH ALLIANCE ID# |
| 14 | 1609962992 | OTHER | ILLINOIS | GREAT WEST ID# |
| 15 | 1609962992 | OTHER | ILLINOIS | UPREHS |
| 16 | 1609962992AA | OTHER | ILLINOIS | ESSENCE ID# |
| 17 | 322675459 | OTHER | ILLINOIS | HMO OF ILLINOIS ID# |
| 18 | 0891394 | OTHER | ILLINOIS | CIGNA ID# |
