Provider Demographics
NPI:1639657414
Name:ADVOCATE NORTH SIDE HEALTH NETWORK
Entity Type:Organization
Organization Name:ADVOCATE NORTH SIDE HEALTH NETWORK
Other - Org Name:ADVOCATE ILLINOIS MASONIC MEDICAL CENTER PSYCH UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:EVP FINANCIAL OPS
Authorized Official - Prefix:
Authorized Official - First Name:NAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-299-1610
Mailing Address - Street 1:836 W WELLINGTON AVE
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:773-975-1600
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
Practice Address - Country:US
Practice Address - Phone:773-975-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005165273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-006Medicaid
IL=========-406Medicaid