Provider Demographics
NPI:1043327091
Name:RESURRECTION SERVICES
Entity Type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:NILES MEDICAL ASSOCIATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-583-6818
Mailing Address - Street 1:7157 W HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3757
Mailing Address - Country:US
Mailing Address - Phone:847-647-1771
Mailing Address - Fax:847-647-5981
Practice Address - Street 1:7157 W HOWARD ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3757
Practice Address - Country:US
Practice Address - Phone:847-647-1771
Practice Address - Fax:847-647-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD93390Medicare UPIN
ILC44069Medicare UPIN
IL392600Medicare ID - Type Unspecified