Provider Demographics
NPI:1124021266
Name:ALVERNO LAKESIDE CORPORATION
Entity Type:Organization
Organization Name:ALVERNO LAKESIDE CORPORATION
Other - Org Name:ALVERNO ADVANCED LIFE SUPPORT SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SLYKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-747-4000
Mailing Address - Street 1:20201 CRAWFORD AVE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1010
Mailing Address - Country:US
Mailing Address - Phone:708-747-4000
Mailing Address - Fax:708-755-3392
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1010
Practice Address - Country:US
Practice Address - Phone:708-756-1200
Practice Address - Fax:708-481-5583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JAMES HOSPITAL, UNITED STATES CATHOLIC CONFERENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-23
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL77967341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590014070OtherMEDICARE RAILROAD
IL1626513OtherBCBS PROVIDER NUMBER
IL=========02Medicaid
IL=========02Medicaid