Basic Information
| Provider Information | |||||||||
| NPI: | 1912014564 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVOCATE NORTH SIDE HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ADVOCATE ILLINOIS MASONIC MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739751600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739751600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | NAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP FINANCIAL OPS | ||||||||
| AuthorizedOfficialTelephone: | 4142991610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 273R00000X | IL | N | Hospital Units | Psychiatric Unit | 273Y00000X | 273Y00000X | IL | N | Hospital Units | Rehabilitation Unit | 282N00000X | 282N00000X | IL | Y | Hospitals | General Acute Care Hospital |
No ID Information.