Provider Demographics
NPI:1578769212
Name:RESURRECTION SERVICES
Entity Type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:NORRIDGE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-583-6818
Mailing Address - Street 1:7830 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706-3267
Mailing Address - Country:US
Mailing Address - Phone:708-457-8083
Mailing Address - Fax:708-457-8172
Practice Address - Street 1:7830 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-3267
Practice Address - Country:US
Practice Address - Phone:708-457-8083
Practice Address - Fax:708-457-8172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121820Medicaid
IL01637820OtherBLUE CROSS BLUE SHIELD GROUP
IL036119065OtherSTATE LICENSURE
IL036121594OtherSTATE LICENSURE
IL215846OtherMEDICARE GROUP
IL215846OtherMEDICARE GROUP
IL036121594OtherSTATE LICENSURE