Provider Demographics
NPI:1578643755
Name:ALTAGRACIA CLINIC SC
Entity Type:Organization
Organization Name:ALTAGRACIA CLINIC SC
Other - Org Name:ALTAGRACIA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GHASSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ASWAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-509-1467
Mailing Address - Street 1:3754 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618
Mailing Address - Country:US
Mailing Address - Phone:773-509-1467
Mailing Address - Fax:773-509-1695
Practice Address - Street 1:3754 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618
Practice Address - Country:US
Practice Address - Phone:773-509-1467
Practice Address - Fax:773-509-1695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1629946OtherB/C B/S
IL1629946OtherB/C B/S
IL=========-60618-1Medicaid