Basic Information
| Provider Information | |||||||||
| NPI: | 1881861490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVOCATE ILLINOIS MASONIC MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | ROOM 7403 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739751600 | ||||||||
| FaxNumber: | 7732967486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | RAMOS | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RESIDENCY PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7732967046 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCATE HEALTH CARE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125-053063 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.