Healthcare Provider Details

I. General information

NPI: 1689886889
Provider Name (Legal Business Name): ADVOCATE NORTH SIDE HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 N DAMEN AVE
CHICAGO IL
60625-1317
US

IV. Provider business mailing address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-1358
  • Fax: 773-275-1853
Mailing address:
  • Phone: 773-296-7081
  • Fax: 773-296-5251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateIL

VIII. Authorized Official

Name: SUSAN NORDSTROM LOPEZ
Title or Position: PRESIDENT
Credential:
Phone: 773-296-7081