Provider Demographics
NPI:1659650414
Name:RESURRECTION SERVICES
Entity Type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:RMG LITTLE VILLAGE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MC CORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
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:708-583-9870
Practice Address - Street 1:3814 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3807
Practice Address - Country:US
Practice Address - Phone:773-522-5200
Practice Address - Fax:773-522-5356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL745367OtherMEDICARE PTAN