MEDICARE: MICHIGAN AVENUE INTERNISTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician		IL
2	207R00000X	Internal Medicine Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01605414	OTHER	IL	BC/BS OF ILLINOIS #

General Provider Information

NPI Number	:	1922066588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN AVENUE INTERNISTS

Provider Business Mailing Address
First Line	:	200 S MICHIGAN AVE
Second Line	:	SUITE 805
City	:	CHICAGO
State	:	IL
Zip	:	60604-2402
Country	:	US
Telephone Number	:	312-922-3815
Fax Number	:	312-922-3789

Provider Business Practice Location Address
First Line	:	200 S MICHIGAN AVE
Second Line	:	SUITE 805
City	:	CHICAGO
State	:	IL
Zip	:	60604-2402
Country	:	US
Telephone Number	:	312-922-3815
Fax Number	:	312-922-3789

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GREG DONALD EWERT
Credential	:	M.D.
Telephone Number	:	312-922-3815

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	09/11/2025

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Directions to “MICHIGAN AVENUE INTERNISTS ” Practice Location

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