Healthcare Provider Details

I. General information

NPI: 1285503797
Provider Name (Legal Business Name): RUSH OAK PARK PHYSICIANS GROUP LAKE STREET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 W MONROE ST STE 100
CHICAGO IL
60606
US

IV. Provider business mailing address

1700 W VAN BUREN ST STE 161
CHICAGO IL
60612-3228
US

V. Phone/Fax

Practice location:
  • Phone: 888-663-6331
  • Fax: 415-252-7176
Mailing address:
  • Phone: 312-563-4577
  • Fax: 312-563-4777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRADEN MANTEI
Title or Position: VP MEDICAL GROUP OPERATIONS
Credential:
Phone: 312-942-3404