Provider Demographics
NPI:1710092473
Name:HYDE PARK ASSOCIATES IN MEDICINE LTD
Entity Type:Organization
Organization Name:HYDE PARK ASSOCIATES IN MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-493-8212
Mailing Address - Street 1:1515 E 52ND PL
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4390
Mailing Address - Country:US
Mailing Address - Phone:773-493-8212
Mailing Address - Fax:773-955-2166
Practice Address - Street 1:1515 E 52ND PL
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4390
Practice Address - Country:US
Practice Address - Phone:773-493-8212
Practice Address - Fax:773-955-2166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001616367OtherBLUE CROSS BLUE SHIELD
0005485045OtherAETNA
CF1260OtherRR MEDICARE
IL0001616367OtherBLUE CROSS BLUE SHIELD
=========OtherCIGNA
0005485045OtherAETNA
604250Medicare ID - Type Unspecified