# ILLINOIS CARDIOVASCULAR & THORACIC SURGERY, LTD

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1962450734
- **Authorized official:** DR. GLEN B SMITH M.D. (CHIREF OPERATIONS OFFICER)
- **Authorized official phone:** (309) 662-5506

## Contact information

- **Practice address:** 1505 EASTLAND DR, SUITE 210, BLOOMINGTON, IL 61701-7906
- **Practice address phone:** (309) 662-5506
- **Practice address fax:** (309) 662-5443
- **Mailing address:** 1505 EASTLAND DR, SUITE 210, BLOOMINGTON, IL 61701-7906
- **Mailing address phone:** (309) 662-5506
- **Mailing address fax:** (309) 662-5443

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RC0000X | Cardiovascular Disease Physician | — | NULL | — |
| 207RC0000X | Cardiovascular Disease Physician | — | — | — |
| 207RI0011X | Interventional Cardiology Physician | — | NULL | — |
| 207RI0011X | Interventional Cardiology Physician | — | — | — |
| 207UN0901X | Nuclear Cardiology Physician | — | NULL | — |
| 207UN0901X | Nuclear Cardiology Physician | — | — | — |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | NULL | — |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | — | — |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | NULL | Yes |
| 208G00000X | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician | — | — | Yes |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |

## Other

- **Enumeration date:** 05/04/2006
- **Last updated:** 04/24/2012