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 | 174400000X | Specialist | | 036-064782 | ILLINOIS | No |
| 2 | 207RI0011X | Internal Medicine | Interventional Cardiology | 036-064782 | 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 | 1164530713 | OTHER | ILLINOIS | GROUP NPI NUMBER FOR CONSULTANTS IN CARDIOVASCULAR MEDICINE S C |
| 2 | 31602469 | OTHER | ILLINOIS | BLUECROSS BLUE SHIELD GROUP PROVIDER NUMBER |
| 3 | L18915 | OTHER | ILLINOIS | MEDICARE PTAN NUMBER |
| 4 | 110032830 | OTHER | ILLINOIS | RAILROAD MEDICARE INDIVIDUAL PROVIDER ID NUMBER |
| 5 | 216577 | OTHER | ILLINOIS | MEDICARE GROUP PTAN FOR LOCALITY 015 |
| 6 | 036-064782 | MEDICAID | ILLINOIS | |
| 7 | K51366 | OTHER | ILLINOIS | MEDICARE INDIVIDUAL PTAN FOR LOALITY 015 |
| 8 | 209712 | OTHER | ILLINOIS | MEDICARE GROUP NUMBER |
| 9 | 961280 | OTHER | ILLINOIS | MEDICARE GROUP NUMBER FOR CONSULTANTS IN CARDIOVASCULAR MEDICINE, S.C. |
| 10 | CC1592 | OTHER | ILLINOIS | RAILROAD MEDICARE GROUP PTAN NUMBER |