Provider Demographics
NPI:1962417485
Name:CARDIAC THORACIC & ENDOVASCULAR THERAPIES, S.C.
Entity type:Organization
Organization Name:CARDIAC THORACIC & ENDOVASCULAR THERAPIES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BERTRAM
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-680-8666
Mailing Address - Street 1:2420 W NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3112
Mailing Address - Country:US
Mailing Address - Phone:309-680-5000
Mailing Address - Fax:309-680-1002
Practice Address - Street 1:2420 W NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-3112
Practice Address - Country:US
Practice Address - Phone:309-680-5000
Practice Address - Fax:309-680-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099138Medicaid
IL7232062OtherBLUE SHIELD PROVIDER NO
ILP00059260OtherRETIRED RAILROAD MEDICARE
ILDS6728OtherRETIRED RAILROAD MEDICARE
ILK09538Medicare PIN
IL209784Medicare PIN
ILD69276Medicare UPIN