Provider Demographics
NPI:1316014384
Name:ADVENT MEDICAL CORP
Entity Type:Organization
Organization Name:ADVENT MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-230-6202
Mailing Address - Street 1:4800 S CHICAGO BEACH DR
Mailing Address - Street 2:901-N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-7032
Mailing Address - Country:US
Mailing Address - Phone:773-230-6202
Mailing Address - Fax:773-289-0888
Practice Address - Street 1:4800 S CHICAGO BEACH DR
Practice Address - Street 2:901-N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-7032
Practice Address - Country:US
Practice Address - Phone:773-230-6202
Practice Address - Fax:773-289-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056166208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212965Medicare ID - Type Unspecified