Healthcare Provider Details

I. General information

NPI: 1326775594
Provider Name (Legal Business Name): ALAMO WOMEN'S CLINIC OF ILLINOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W MAIN ST
CARBONDALE IL
62901-1087
US

IV. Provider business mailing address

2800 W MAIN ST
CARBONDALE IL
62901-1087
US

V. Phone/Fax

Practice location:
  • Phone: 800-821-7237
  • Fax:
Mailing address:
  • Phone: 618-351-2253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number State

VIII. Authorized Official

Name: ANDREA GALLEGOS
Title or Position: EXECUTIVE ADMINISTRATOR
Credential: LMSW
Phone: 210-842-9069