1609809565 NPI number — ALSIP INTEGRATED MEDICAL CENTER S C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609809565 NPI number — ALSIP INTEGRATED MEDICAL CENTER S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALSIP INTEGRATED MEDICAL CENTER S C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609809565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9721 165TH ST
Provider Second Line Business Mailing Address:
STE 21
Provider Business Mailing Address City Name:
ORLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60467-5657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-388-7500
Provider Business Mailing Address Fax Number:
708-942-8102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9721 165TH ST
Provider Second Line Business Practice Location Address:
STE 21
Provider Business Practice Location Address City Name:
ORLAND PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60467-5657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-388-7500
Provider Business Practice Location Address Fax Number:
708-942-8102
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOROS
Authorized Official First Name:
BECKY
Authorized Official Middle Name:
ARLENE
Authorized Official Title or Position:
CLINIC DIRECTOR OWNER
Authorized Official Telephone Number:
708-388-7500

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  042617005 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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