Healthcare Provider Details

I. General information

NPI: 1356647960
Provider Name (Legal Business Name): RESURRECTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR 7 EAST
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

PO BOX 564437
CHICAGO IL
60656-4437
US

V. Phone/Fax

Practice location:
  • Phone: 773-661-5800
  • Fax:
Mailing address:
  • Phone: 708-583-7310
  • Fax: 708-583-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036058899
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036120969
License Number StateIL

VIII. Authorized Official

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