Basic Information
| Provider Information | |||||||||
| NPI: | 1699962696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL AND INTERVENTIONAL CARDIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9669 KENTON AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600761266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476761333 | ||||||||
| FaxNumber: | 8476761727 | ||||||||
| Practice Location | |||||||||
| Address1: | 9669 KENTON AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600761266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476761333 | ||||||||
| FaxNumber: | 8476761727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GILPIN | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | JOSE | ||||||||
| AuthorizedOfficialTitleorPosition: | CERTIFIED MEDICAL ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 8476761333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CMA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1635694 | 01 | BCBS | OTHER |