Healthcare Provider Details

I. General information

NPI: 1780850404
Provider Name (Legal Business Name): ADVOCATE ILLINOIS MASONIC MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 N WILTON AVE 2ND FLOOR
CHICAGO IL
60657-6710
US

IV. Provider business mailing address

836 W WELLINGTON AVE ROOM 7403
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5424
  • Fax: 773-296-5280
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125053624
License Number StateIL

VIII. Authorized Official

Name: DR. TERESA RAMOS
Title or Position: RESIDENCY PROGRAM DIRECTOR
Credential:
Phone: 773-296-7046