Basic Information
| Provider Information | |||||||||
| NPI: | 1629478359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALIVIO MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALIVIO MEDICAL CENTER AT BENITO JUAREZ COMMUNITY ACADEMY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 966 WEST 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 3128296375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450-1510 W. CERMAK ROAD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2014 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | CORPUZ | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.E.O | ||||||||
| AuthorizedOfficialTelephone: | 3128296304 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.