Healthcare Provider Details

I. General information

NPI: 1891174983
Provider Name (Legal Business Name): ADVOCATE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 N WILTON AVE 3RD FLOOR, NURSE-MIDWIFERY SERVICE
CHICAGO IL
60657-6710
US

IV. Provider business mailing address

3048 N WILTON AVE 3RD FLOOR, NURSE-MIDWIFERY SERVICE
CHICAGO IL
60657-6710
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7032
  • Fax: 773-296-3096
Mailing address:
  • Phone: 773-296-7032
  • Fax: 773-296-3096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209012585
License Number StateIL

VIII. Authorized Official

Name: MS. LISE HAUSER
Title or Position: SUPERVISOR, NURSE-MIDWIFERY SERVICE
Credential: CNM
Phone: 773-296-3098