Provider Demographics
NPI:1396032462
Name:RESURRECTION SERVICES
Entity Type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:708-583-6817
Mailing Address - Street 1:PO BOX 564437
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-4437
Mailing Address - Country:US
Mailing Address - Phone:708-583-7310
Mailing Address - Fax:
Practice Address - Street 1:2900 N LAKE SHORE DR
Practice Address - Street 2:SUITE 1208
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5640
Practice Address - Country:US
Practice Address - Phone:773-665-4964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109067Medicaid