MEDICARE: HYDE PARK ASSOCIATES IN MEDICINE 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	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CF1260	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001616367	OTHER	IL	BLUE CROSS BLUE SHIELD
2	0005485045	OTHER		AETNA

General Provider Information

NPI Number	:	1710092473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYDE PARK ASSOCIATES IN MEDICINE LTD

Provider Business Mailing Address
First Line	:	1515 E 52ND PL
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60615-4390
Country	:	US
Telephone Number	:	773-493-8212
Fax Number	:	773-955-2166

Provider Business Practice Location Address
First Line	:	1515 E 52ND PL
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60615-4390
Country	:	US
Telephone Number	:	773-493-8212
Fax Number	:	773-955-2166

Authorized Official
Title or Position	:	PHYSICIAN MANAGER
Name	:	STEPHANIE WEAVER
Credential	:	M.D.
Telephone Number	:	773-493-8212

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	08/22/2020

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