Provider Demographics
NPI:1922115864
Name:PRESENCE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESENCE HEALTHCARE SERVICES
Other - Org Name:RESURRECTION SERVICES PRESENCE MEDICAL GROUP
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 1:9000 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3508
Practice Address - Country:US
Practice Address - Phone:773-731-0670
Practice Address - Fax:773-731-1714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053397207R00000X
IL036054086207R00000X
207R00000X
IL209007288363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053397Medicaid
IL209007288OtherSTATE LICENSE
IL036054086Medicaid
ILC42300Medicare UPIN
ILD13338Medicare UPIN
IL036054086Medicaid
IL036053397Medicaid