Individual
DR. CHARLES CLIFFORD ALSTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2017 W 95TH ST, CHICAGO, CHICAGO, IL 60643-1115
(773) 779-2800
(773) 779-0556
Mailing address
9215 S PLEASANT AVE, CHICAGO, CHICAGO, IL 60620-5514
(773) 779-2800
(773) 779-0556
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
036061393
IL
207V00000X
Obstetrics & Gynecology Physician
Primary
036061393
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036061393
—
IL
01
—
21609820
BLUE CROSS BLUE SHIED
IL
01
—
363472580
FEDERAL TAX ID
IL
Enumeration date
02/01/2006
Last updated
11/06/2012
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