Healthcare Provider Details

I. General information

NPI: 1386897700
Provider Name (Legal Business Name): SUSANA CORALIA ALVAREZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSANA CORALIA ALVAREZ-BANKS M.D.

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 MAPLE AVE
BLUE ISLAND IL
60406-2318
US

IV. Provider business mailing address

13000 MAPLE AVE
BLUE ISLAND IL
60406-2318
US

V. Phone/Fax

Practice location:
  • Phone: 708-385-6100
  • Fax: 708-385-2051
Mailing address:
  • Phone: 708-385-6100
  • Fax: 708-385-2051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.122436
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01051236A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: