Basic Information
| Provider Information | |||||||||
| NPI: | 1548598915 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALIVIO MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALIVIO MEDICAL CENTER AT JOSE CLEMENTE OROZCO COMMUNITY ACADEMY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 966 W. 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 3128296375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1940 W. 18TH STREET | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606081903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 3128296375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2009 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | CORPUZ | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3128296304 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QS1000X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
| ID | Type | State | Issuer | Description | 1618612 | 01 | IL | BCBS | OTHER |