Provider Demographics
NPI:1396916409
Name:SOUTHTOWN ALLERGY AND ASTHMA CARE, PC
Entity type:Organization
Organization Name:SOUTHTOWN ALLERGY AND ASTHMA CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:JAEN
Authorized Official - Last Name:ALCORDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-945-6328
Mailing Address - Street 1:18210 LA GRANGE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7722
Mailing Address - Country:US
Mailing Address - Phone:708-945-6328
Mailing Address - Fax:
Practice Address - Street 1:18210 LA GRANGE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7722
Practice Address - Country:US
Practice Address - Phone:708-945-6328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083285261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36152Medicare UPIN
599270Medicare PIN