Provider Demographics
NPI:1740361021
Name:RESURRECTION PHYSICIANS PROVIDER GROUP
Entity type:Organization
Organization Name:RESURRECTION PHYSICIANS PROVIDER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLINGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-527-5210
Mailing Address - Street 1:5860 W HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2372
Mailing Address - Country:US
Mailing Address - Phone:773-695-4800
Mailing Address - Fax:773-864-9416
Practice Address - Street 1:5860 W HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2372
Practice Address - Country:US
Practice Address - Phone:773-695-4800
Practice Address - Fax:773-864-9416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization