Provider Demographics
NPI:1982878856
Name:DR.CHARLES CLIFFORD ALSTON SC
Entity Type:Organization
Organization Name:DR.CHARLES CLIFFORD ALSTON SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-779-2801
Mailing Address - Street 1:2017 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2017 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1115
Practice Address - Country:US
Practice Address - Phone:773-779-2280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
IL=========OtherBLUE CROSS BLUE SHIELD
IL=========OtherBLUE CROSS BLUE SHIELD