Provider Demographics
NPI:1285791939
Name:ADVOCATE ILLNOIS MASONIC MEDICAL CENTER
Entity type:Organization
Organization Name:ADVOCATE ILLNOIS MASONIC MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC CRITICAL CARE
Authorized Official - Prefix:
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:IOSIF
Authorized Official - Last Name:NICA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-975-1600
Mailing Address - Street 1:4200 N MARINE DR
Mailing Address - Street 2:APT.303
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1743
Mailing Address - Country:US
Mailing Address - Phone:773-327-8826
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-975-1600
Practice Address - Fax:773-296-7459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082690146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Multi-Specialty