Healthcare Provider Details

I. General information

NPI: 1861785123
Provider Name (Legal Business Name): RESURRECTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 W PETERSON AVE SUITE 300
CHICAGO IL
60659-3306
US

IV. Provider business mailing address

PO BOX 564437
CHICAGO IL
60656-4437
US

V. Phone/Fax

Practice location:
  • Phone: 773-961-3200
  • Fax: 773-867-6793
Mailing address:
  • Phone: 708-583-7310
  • Fax: 708-583-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036101307
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036047714
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036079521
License Number StateIL

VIII. Authorized Official

Name: DANIEL MCCORMICK
Title or Position: SENIOR VICE PRESIDENT
Credential: FACHE
Phone: 708-583-6817