Healthcare Provider Details

I. General information

NPI: 1417341249
Provider Name (Legal Business Name): ALIVIO MEDICAL CENTER-JUAREZ HIGH SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 W CERMAK RD
CHICAGO IL
60608-4408
US

IV. Provider business mailing address

2355 S WESTERN AVE
CHICAGO IL
60608-3837
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax: 312-733-3563
Mailing address:
  • Phone: 773-254-1400
  • Fax: 312-733-3563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number771115088
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number771115008
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number771115088
License Number StateIL

VIII. Authorized Official

Name: MRS. ESTHER CORPUZ
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: C.E.O.
Phone: 312-829-6304