Provider Demographics
NPI:1538355136
Name:RUSH CENTER FOR CONGENITAL & STRUCTURAL HEART DISEASE
Entity type:Organization
Organization Name:RUSH CENTER FOR CONGENITAL & STRUCTURAL HEART DISEASE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-942-6909
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:770 JONES
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-6800
Mailing Address - Fax:312-942-5360
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:708 KELLOGG
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSH UNIVERSITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-18
Last Update Date:2008-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RC0000X
IL2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01638445OtherBC PIN
IL01638445OtherBC PIN