Provider Demographics
NPI:1477553899
Name:ALCORDO, MIGUEL JAEN (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:JAEN
Last Name:ALCORDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16828 GREEN KNOLL AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5857
Mailing Address - Country:US
Mailing Address - Phone:708-478-6093
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:708-478-1286
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083285207RA0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36152Medicare UPIN