Provider Demographics
NPI:1275726085
Name:PRESTON HEALTH PARTNERS P C
Entity Type:Organization
Organization Name:PRESTON HEALTH PARTNERS P C
Other - Org Name:PRESTON FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-784-9000
Mailing Address - Street 1:4479 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1714
Mailing Address - Country:US
Mailing Address - Phone:708-784-9000
Mailing Address - Fax:708-784-9088
Practice Address - Street 1:4479 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1714
Practice Address - Country:US
Practice Address - Phone:708-784-9000
Practice Address - Fax:708-784-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080973261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50780OtherTRICARE
IL0021605429OtherBLUE CROSS BLUE SHIELD
IL036080973Medicaid
IL50780OtherTRICARE
IL50780OtherTRICARE
IL=========OtherCOMMERICAL