Provider Demographics
NPI:1861579377
Name:CARDIAC ASSOCIATES SC
Entity type:Organization
Organization Name:CARDIAC ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHODWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-284-1234
Mailing Address - Street 1:PO BOX 64568
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-4568
Mailing Address - Country:US
Mailing Address - Phone:630-288-6200
Mailing Address - Fax:
Practice Address - Street 1:6441 S PULASKI RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5148
Practice Address - Country:US
Practice Address - Phone:773-284-1234
Practice Address - Fax:773-284-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065163Medicaid
IL01636774OtherBCBS PROVIDER ID
ILCF1085OtherRAILROAD MEDICARE
ILD16177Medicare UPIN
IL214340Medicare PIN