NPIMap

Organization Active NPI

Premier Vascular, LLC

  • Interventional Cardiology Physician
  • Merrionette Park, IL
National Provider Identifier
1366890782
Registry record updated Oct 25, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Cardiology PhysicianTaxonomy code 207RI0011X
Legal business name
PREMIER VASCULAR, LLC
Practice address
11560 S Kedzie Ave
Merrionette Park, IL 60803-4517
Phone
(708) 478-3600
Fax
(708) 478-3553
NPI assigned
May 26, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 25, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Mark Berlin
Title
Coo
Phone
(708) 478-3600

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Cardiovascular Disease PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RC0000X
Clinical Cardiac Electrophysiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RC0001X
Interventional Cardiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RI0011X Primary

Addresses

Primary practice location

11560 S Kedzie Ave
Merrionette Park, IL 60803-4517

Mailing address

11560 S Kedzie Ave
Merrionette Park, IL 60803-4517
Phone (708) 972-7525

Other identifiers 1

IdentifierTypeStateIssuer
F100329328OtherILMEDICARE PTAN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160929001415 IL Part B Supplier - Clinic/Group Practice 7719274042 Receives reassigned benefits from 7 practitioners
Practice locations: Merrionette Park, IL

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

11560 S Kedzie Ave
Merrionette Park, IL 60803
Phone (708) 792-0162

11560 S Kedzie Ave
Ste 102
Merrionette Park, IL 60803
Phone (708) 972-7520

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1464220800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1477353600000",
    "number": "1366890782",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11560 S KEDZIE AVE",
            "city": "MERRIONETTE PARK",
            "state": "IL",
            "postal_code": "608034517",
            "telephone_number": "708-972-7525",
            "fax_number": "708-972-7526"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11560 S KEDZIE AVE",
            "city": "MERRIONETTE PARK",
            "state": "IL",
            "postal_code": "608034517",
            "telephone_number": "708-478-3600",
            "fax_number": "708-478-3553"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER VASCULAR, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-05-26",
        "last_updated": "2016-10-25",
        "status": "A",
        "authorized_official_last_name": "BERLIN",
        "authorized_official_first_name": "MARK",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "708-478-3600",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207RC0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RC0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Clinical Cardiac Electrophysiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "F100329328",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Merrionette Park, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.