Provider Demographics
NPI:1306005400
Name:RAVENSWOOD FAMILY PRACTICE
Entity Type:Organization
Organization Name:RAVENSWOOD FAMILY PRACTICE
Other - Org Name:ADVOCATE ILLINOIS MASONIC PHYSICIAN GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:RESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-415-6373
Mailing Address - Street 1:4600 N RAVENSWOOD AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4510
Mailing Address - Country:US
Mailing Address - Phone:773-561-7500
Mailing Address - Fax:773-561-7612
Practice Address - Street 1:4600 N RAVENSWOOD AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4510
Practice Address - Country:US
Practice Address - Phone:773-561-7500
Practice Address - Fax:773-561-7612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125053010282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital