Basic Information
| Provider Information | |||||||||
| NPI: | 1124274311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALIVIO MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALIVIO MEDICAL CENTER CICERO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 966 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 3128296673 | ||||||||
| Practice Location | |||||||||
| Address1: | 4842 W CERMAK RD | ||||||||
| Address2: | |||||||||
| City: | CICERO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608042531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128296304 | ||||||||
| FaxNumber: | 7086600349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2008 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | CORPUZ | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3128296304 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | IL | MEDICAID | 0001618612 | 01 | IL | BCBS | OTHER | 920890 | 01 | IL | MEDICARE GROUP NUMBER | OTHER |