=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316014384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVENT MEDICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 09/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 S CHICAGO BEACH DR 901-N
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-7032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-230-6202
-----------------------------------------------------
Fax | 773-289-0888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4800 S CHICAGO BEACH DR 901-N
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-7032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-230-6202
-----------------------------------------------------
Fax | 773-289-0888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. MARY BAHL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-230-6202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036056166
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------