Provider Demographics
NPI:1760701841
Name:PRESENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESENCE HEALTHCARE SERVICES
Other - Org Name:PRESENCE MEDICAL GROUP - RHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKLIFFE-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-914-2417
Mailing Address - Street 1:1000 REMINGTON BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-0000
Mailing Address - Country:US
Mailing Address - Phone:630-914-2417
Mailing Address - Fax:630-914-2499
Practice Address - Street 1:5308 NORTH BELMONT AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-0000
Practice Address - Country:US
Practice Address - Phone:773-427-8114
Practice Address - Fax:773-472-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121746207Y00000X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147001095OtherAUDIOLOGY LICENSE
IL036126439Medicaid
IL036121746Medicaid
745367Medicare PIN