Provider Demographics
NPI:1124274311
Name:ALIVIO MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:ALIVIO MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CORPUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-829-6304
Mailing Address - Street 1:966 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4511
Mailing Address - Country:US
Mailing Address - Phone:773-254-1400
Mailing Address - Fax:312-829-6673
Practice Address - Street 1:4842 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2531
Practice Address - Country:US
Practice Address - Phone:312-829-6304
Practice Address - Fax:708-660-0349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid
IL0001618612OtherBCBS
IL920890OtherMEDICARE GROUP NUMBER
ILPENDINGMedicare Oscar/Certification