MEDICARE: MICHIGAN AVENUE CENTER FOR HEALTH, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	7002777	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50422	OTHER	IL	BC BS NUMBER

General Provider Information

NPI Number	:	1518002658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN AVENUE CENTER FOR HEALTH, LTD.

Provider Business Mailing Address
First Line	:	PO BOX 661066
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60666-1066
Country	:	US
Telephone Number	:	847-255-7400
Fax Number	:	847-398-4585

Provider Business Practice Location Address
First Line	:	2415 S MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2301
Country	:	US
Telephone Number	:	312-328-1200
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT ADMINISTRATOR
Name	:	TAMMY STERN
Credential	:
Telephone Number	:	847-255-7400

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	08/22/2020

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