Basic Information
| Provider Information | |||||||||
| NPI: | 1669617007 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALIVIO MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALIVIO MEDICAL CENTER AT JOHN SPRY COMMUNITY SCHOOL | ||||||||
| 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: | 3128296673 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 S. MARSHALL BLVD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606234146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2008 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | CORPUZ | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
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| 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 | 1041S0200X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 261QC1500X | IL | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QS1000X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
| ID | Type | State | Issuer | Description | 141854 | 01 | IL | TPAN | OTHER | 141077 | 01 | IL | TPAN MORGAN | OTHER | 1618612 | 01 | IL | BCBS | OTHER |