Provider Demographics
NPI:1821191867
Name:PRESENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESENCE HEALTHCARE SERVICES
Other - Org Name:RESURRECTION SERVICES
Other - Org Type:Former Legal Business Name
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 1:800 AUSTIN ST
Practice Address - Street 2:SUITE #451 EAST TOWER
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-316-6611
Practice Address - Fax:847-316-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042217Medicaid
IL036113363Medicaid
IL036042217Medicaid
745367Medicare PIN
IL391910Medicare ID - Type Unspecified
ILC44490Medicare UPIN