MEDICARE: DR. CHARLES CLIFFORD ALSTON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036061393	IL
2	207V00000X	Obstetrics & Gynecology Physician	036061393	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	363472580	OTHER	IL	FEDERAL TAX ID
3	21609820	OTHER	IL	BLUE CROSS BLUE SHIED

General Provider Information

NPI Number	:	1922070382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES CLIFFORD ALSTON MD

Provider Business Mailing Address
First Line	:	9215 S PLEASANT AVE
Second Line	:	CHICAGO
City	:	CHICAGO
State	:	IL
Zip	:	60620-5514
Country	:	US
Telephone Number	:	773-779-2800
Fax Number	:	773-779-0556

Provider Business Practice Location Address
First Line	:	2017 W 95TH ST
Second Line	:	CHICAGO
City	:	CHICAGO
State	:	IL
Zip	:	60643-1115
Country	:	US
Telephone Number	:	773-779-2800
Fax Number	:	773-779-0556

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	11/06/2012

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Directions to “ DR. CHARLES CLIFFORD ALSTON MD” Practice Location

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