Provider Demographics
NPI:1114189255
Name:ADVOCATE ILLINOIS MASONIC MEDICAL CENTER
Entity Type:Organization
Organization Name:ADVOCATE ILLINOIS MASONIC MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENCY PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-296-7046
Mailing Address - Street 1:836 W WELLINGTON AVE RM 7403
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3048 N WILTON AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6710
Practice Address - Country:US
Practice Address - Phone:773-296-5424
Practice Address - Fax:773-296-5280
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVOCATE HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125054918207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty