Healthcare Provider Details

I. General information

NPI: 1619213170
Provider Name (Legal Business Name): ADVANCED HEALTH INSTITUTE SOUTH LOOP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 S WABASH AVE STE 250
CHICAGO IL
60605-2355
US

IV. Provider business mailing address

1147 S WABASH AVE STE 250
CHICAGO IL
60605-2355
US

V. Phone/Fax

Practice location:
  • Phone: 312-987-4878
  • Fax: 312-235-0900
Mailing address:
  • Phone: 312-987-4878
  • Fax: 312-235-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011556
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036134095
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036112926
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036060139
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003927
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209011079
License Number StateIL

VIII. Authorized Official

Name: MATTHEW WALKER
Title or Position: CEO
Credential:
Phone: 847-910-2567