Provider Demographics
NPI:1689886889
Name:ADVOCATE NORTH SIDE HEALTH NETWORK
Entity Type:Organization
Organization Name:ADVOCATE NORTH SIDE HEALTH NETWORK
Other - Org Name:ADMUNSEN SCHOOL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORDSTROM LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-296-7081
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:773-296-7081
Mailing Address - Fax:773-296-5251
Practice Address - Street 1:5110 N DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1317
Practice Address - Country:US
Practice Address - Phone:773-275-1358
Practice Address - Fax:773-275-1853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========014Medicaid