Basic Information
Provider Information
NPI: 1427369693
EntityType: 2
ReplacementNPI:  
OrganizationName: ALIVIO MEDICAL CENTER, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ALIVIO MEDICAL CENTER @ LITTLE VILLAGE/LAWNDALE HIGH SCHOOL
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 966 W 21ST ST
Address2:  
City: CHICAGO
State: IL
PostalCode: 606084511
CountryCode: US
TelephoneNumber: 7732141400
FaxNumber: 3128296375
Practice Location
Address1: 3120 S KOSTNER AVE
Address2:  
City: CHICAGO
State: IL
PostalCode: 606234842
CountryCode: US
TelephoneNumber: 3128296327
FaxNumber: 3128296375
Other Information
ProviderEnumerationDate: 06/23/2010
LastUpdateDate: 02/26/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: CORPUZ
AuthorizedOfficialFirstName: ESTHER
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 3128296304
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QF0400X  N Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
261QS1000X  Y Ambulatory Health Care FacilitiesClinic/CenterStudent Health

ID Information
IDTypeStateIssuerDescription
000161861201ILBCBSOTHER


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