Provider Demographics
NPI:1629478359
Name:ALIVIO MEDICAL CENTER
Entity Type:Organization
Organization Name:ALIVIO MEDICAL CENTER
Other - Org Name:ALIVIO MEDICAL CENTER AT BENITO JUAREZ COMMUNITY ACADEMY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O
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 WEST 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4409
Mailing Address - Country:US
Mailing Address - Phone:773-254-1400
Mailing Address - Fax:312-829-6375
Practice Address - Street 1:1450-1510 W. CERMAK ROAD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:773-254-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
261QF0400X, 261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent HealthGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid
ILPENDINGOtherMEDICARE PTAN