Provider Demographics
NPI:1861785123
Name:RESURRECTION SERVICES
Entity type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:708-583-6817
Mailing Address - Street 1:PO BOX 564437
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-4437
Mailing Address - Country:US
Mailing Address - Phone:708-583-7310
Mailing Address - Fax:708-583-9870
Practice Address - Street 1:3500 W PETERSON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3306
Practice Address - Country:US
Practice Address - Phone:773-961-3200
Practice Address - Fax:773-867-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101307207Q00000X
IL036047714207R00000X
IL036079521207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047714Medicaid
IL745367OtherMEDICARE PTAN
IL036101307Medicaid
IL036079521Medicaid