Healthcare Provider Details

I. General information

NPI: 1376102764
Provider Name (Legal Business Name): ANIBAL ENRIQUE GONZALEZ ALVAREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST STE 403
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

600 S PAULINA ST STE 403
CHICAGO IL
60612-3806
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5495
  • Fax:
Mailing address:
  • Phone: 312-942-5495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125082370
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: