Provider Demographics
NPI:1821203621
Name:ADVOCATE NORTH SIDE HEALTH NETWORK
Entity Type:Organization
Organization Name:ADVOCATE NORTH SIDE HEALTH NETWORK
Other - Org Name:LAKE VIEW SCHOOL HEALTH CENTER
Other - Org Type:Other Name
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:
Mailing Address - Fax:
Practice Address - Street 1:4015 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2593
Practice Address - Country:US
Practice Address - Phone:773-404-0447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========013Medicaid