Provider Demographics
NPI:1922070382
Name:ALSTON, CHARLES CLIFFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CLIFFORD
Last Name:ALSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9215 S PLEASANT AVE
Mailing Address - Street 2:CHICAGO
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5514
Mailing Address - Country:US
Mailing Address - Phone:773-779-2800
Mailing Address - Fax:773-779-0556
Practice Address - Street 1:2017 W 95TH ST
Practice Address - Street 2:CHICAGO
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1115
Practice Address - Country:US
Practice Address - Phone:773-779-2800
Practice Address - Fax:773-779-0556
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036061393207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061393Medicaid
IL363472580OtherFEDERAL TAX ID
IL21609820OtherBLUE CROSS BLUE SHIED
ILD14827Medicare UPIN
IL036061393Medicaid