Provider Demographics
NPI:1306070784
Name:ALIVIO MEDICAL CENTER
Entity type:Organization
Organization Name:ALIVIO MEDICAL CENTER
Other - Org Name:
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 1:966 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4511
Practice Address - Country:US
Practice Address - Phone:773-254-1400
Practice Address - Fax:312-829-6673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1138738261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6060808Medicaid
IL=========6060811Medicaid