Provider Demographics
NPI:1255646857
Name:ALIVIO MEDICAL CENTER INC
Entity type:Organization
Organization Name:ALIVIO MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
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 W. 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4511
Mailing Address - Country:US
Mailing Address - Phone:773-254-1400
Mailing Address - Fax:312-829-6375
Practice Address - Street 1:6447 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2311
Practice Address - Country:US
Practice Address - Phone:312-829-6870
Practice Address - Fax:312-829-6375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
0001618612OtherBCBS
IL036113015 3Medicaid
IL141077OtherMEDICARE TPAN NUMBER
IL920890OtherMEDICARE TPAN
IL141854OtherMEDICARE TPAN NUMBER