Provider Demographics
NPI:1730296641
Name:RESURRECTION SERVICES
Entity Type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:FORREST ROBINSON, DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-583-6818
Mailing Address - Street 1:9855 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-2758
Mailing Address - Country:US
Mailing Address - Phone:708-345-3076
Mailing Address - Fax:708-345-9984
Practice Address - Street 1:9855 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2758
Practice Address - Country:US
Practice Address - Phone:708-345-3076
Practice Address - Fax:708-345-9984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF03178Medicare UPIN
IL211028Medicare ID - Type Unspecified