=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275913063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVOCATE HEALTH AND HOSPITALS CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2015
-----------------------------------------------------
Last Update Date | 04/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 W 95TH ST STE 205
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-2574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-296-3130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4700 W 95TH ST STE 205
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-2574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR BUSINESS ANALYST
-----------------------------------------------------
Name | PAUL ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-296-6316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------