Provider Demographics
NPI:1609809565
Name:ALSIP INTEGRATED MEDICAL CENTER S C
Entity Type:Organization
Organization Name:ALSIP INTEGRATED MEDICAL CENTER S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:ARLENE
Authorized Official - Last Name:BOROS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-388-7500
Mailing Address - Street 1:9721 165TH ST
Mailing Address - Street 2:STE 21
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5657
Mailing Address - Country:US
Mailing Address - Phone:708-388-7500
Mailing Address - Fax:708-942-8102
Practice Address - Street 1:9721 165TH ST
Practice Address - Street 2:STE 21
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5657
Practice Address - Country:US
Practice Address - Phone:708-388-7500
Practice Address - Fax:708-942-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
042617005261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203234Medicare PIN
ILDC0947Medicare PIN