Provider Demographics
NPI:1306845763
Name:OUR LADY OF THE RESURRECTION MEDICAL CENTER
Entity Type:Organization
Organization Name:OUR LADY OF THE RESURRECTION MEDICAL CENTER
Other - Org Name:ADDISON EMERGENCY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-774-8000
Mailing Address - Street 1:520 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:
Practice Address - Street 1:5645 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4403
Practice Address - Country:US
Practice Address - Phone:773-774-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE RESURRECTION MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-19
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209312Medicare PIN
ILDB9766Medicare PIN