Basic Information
| Provider Information | |||||||||
| NPI: | 1447520291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED CENTER FOR CARDIOTHORACIC SURGERY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 N MICHIGAN ST | ||||||||
| Address2: | 503 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746476500 | ||||||||
| FaxNumber: | 5746476518 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N MICHIGAN ST | ||||||||
| Address2: | 503 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746476500 | ||||||||
| FaxNumber: | 5746476518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2012 | ||||||||
| LastUpdateDate: | 01/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5746476500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 01034778A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.