Basic Information
| Provider Information | |||||||||
| NPI: | 1508031675 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVOCATE ILLINOIS MASONIC MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3048 N WILTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732965424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | RAMOS | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RESIDENCY PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7732965424 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCATE HEALTH CARE | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125-053509 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.