Basic Information
| Provider Information | |||||||||
| NPI: | 1902891377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | ALIX | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 S CLAY ST STE LL30 | ||||||||
| Address2: | |||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302865050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 036109235 | IL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 036109235 | 05 | IL | MEDICAID | P00631982 | 01 | IL | RR MEDICARE | OTHER |