Provider Demographics
NPI:1922066588
Name:MICHIGAN AVENUE INTERNISTS
Entity Type:Organization
Organization Name:MICHIGAN AVENUE INTERNISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:EWERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-922-3815
Mailing Address - Street 1:200 S MICHIGAN AVE
Mailing Address - Street 2:SUITE 805
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-2402
Mailing Address - Country:US
Mailing Address - Phone:312-922-3815
Mailing Address - Fax:312-922-3789
Practice Address - Street 1:200 S MICHIGAN AVE
Practice Address - Street 2:SUITE 805
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-2402
Practice Address - Country:US
Practice Address - Phone:312-922-3815
Practice Address - Fax:312-922-3789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01605414OtherBC/BS OF ILLINOIS #
IL01605414OtherBC/BS OF ILLINOIS #
IL=========OtherTAX ID NUMBER