Provider Demographics
NPI:1306914791
Name:PREVENTIVE CARDIOVASCULAR SERVICES SC
Entity type:Organization
Organization Name:PREVENTIVE CARDIOVASCULAR SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-479-6522
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0187
Mailing Address - Country:US
Mailing Address - Phone:708-479-6522
Mailing Address - Fax:708-479-6597
Practice Address - Street 1:356 W SUPERIOR ST FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3416
Practice Address - Country:US
Practice Address - Phone:312-932-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081595207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081595Medicaid
IL213504Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
IL036081595Medicaid