Provider Demographics
NPI:1831435841
Name:PRESENCE AMBULATORY SERVICES
Entity type:Organization
Organization Name:PRESENCE AMBULATORY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, CREDENTIALING & PROVIDER R
Authorized Official - Prefix:
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 BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-5114
Mailing Address - Country:US
Mailing Address - Phone:630-914-2417
Mailing Address - Fax:
Practice Address - Street 1:9312 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1309
Practice Address - Country:US
Practice Address - Phone:847-329-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESENCE HEALTHCARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-19
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology