Provider Demographics
NPI:1295495208
Name:ALYVE MEDICAL PLLC FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:ALYVE MEDICAL PLLC FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMARDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRESTHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-801-8156
Mailing Address - Street 1:783 ALLENBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7455
Mailing Address - Country:US
Mailing Address - Phone:217-801-8156
Mailing Address - Fax:
Practice Address - Street 1:1480 N GREEN MOUNT RD STE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3466
Practice Address - Country:US
Practice Address - Phone:618-622-3450
Practice Address - Fax:618-622-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty