=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710092473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HYDE PARK ASSOCIATES IN MEDICINE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 E 52ND PL 3RD FLOOR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-493-8212
-----------------------------------------------------
Fax | 773-955-2166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 E 52ND PL 3RD FLOOR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-493-8212
-----------------------------------------------------
Fax | 773-955-2166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN MANAGER
-----------------------------------------------------
Name | STEPHANIE WEAVER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-493-8212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------