Healthcare Provider Details

I. General information

NPI: 1518002658
Provider Name (Legal Business Name): MICHIGAN AVENUE CENTER FOR HEALTH, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 S MICHIGAN AVE
CHICAGO IL
60616-2301
US

IV. Provider business mailing address

PO BOX 661066
CHICAGO IL
60666-1066
US

V. Phone/Fax

Practice location:
  • Phone: 312-328-1200
  • Fax:
Mailing address:
  • Phone: 847-255-7400
  • Fax: 847-398-4585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7002777
License Number StateIL

VIII. Authorized Official

Name: TAMMY STERN
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 847-255-7400