Basic Information
| Provider Information | |||||||||
| NPI: | 1083860845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALIVIO MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 966 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 3128296843 | ||||||||
| Practice Location | |||||||||
| Address1: | ALIVIO MEDICAL CTR | ||||||||
| Address2: | 75 REMITTANCE DR. SUITE 6577 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128296327 | ||||||||
| FaxNumber: | 3128296843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | CORPUZ | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3128296304 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | N | Agencies | Local Education Agency (LEA) | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 920890 | 01 | IL | MEDICARE PART B TPAN | OTHER | 036100871 3 | 05 | IL | MEDICAID | 141077 | 01 | IL | TPAN | OTHER | 036118630 1 | 05 | IL | MEDICAID | 0001618612 | 01 | IL | BCBS | OTHER | 036113015 3 | 05 | IL | MEDICAID |