Healthcare Provider Details

I. General information

NPI: 1174861090
Provider Name (Legal Business Name): ALEXIS C ALVARADO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8687 CONNECTICUT ST STE D
MERILLVILLE IL
46410-5541
US

IV. Provider business mailing address

8687 CONNECTICUT ST STE D
MERILLVILLE IL
46410-5541
US

V. Phone/Fax

Practice location:
  • Phone: 219-750-9630
  • Fax: 219-750-9451
Mailing address:
  • Phone: 219-750-9630
  • Fax: 219-750-9451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-004592
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10001662A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: