Healthcare Provider Details

I. General information

NPI: 1881915585
Provider Name (Legal Business Name): ADVOCATE ILLINOIS MASONIC MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-8250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number125057923
License Number StateIL

VIII. Authorized Official

Name: MS. EVELYN COTTO
Title or Position: RESIDENCY COORDINATOR
Credential:
Phone: 773-296-8250