Provider Demographics
NPI:1114166295
Name:PEDIATRIC HEART SURGERY ASSOCIATES, LLC
Entity type:Organization
Organization Name:PEDIATRIC HEART SURGERY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANI
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENNEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-860-0035
Mailing Address - Street 1:6547 N AVONDALE AVE
Mailing Address - Street 2:#001
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1573
Mailing Address - Country:US
Mailing Address - Phone:773-775-1622
Mailing Address - Fax:773-775-1693
Practice Address - Street 1:311 N WALNUT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1566
Practice Address - Country:US
Practice Address - Phone:630-860-0035
Practice Address - Fax:630-860-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-099190208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty