Healthcare Provider Details

I. General information

NPI: 1366537953
Provider Name (Legal Business Name): PRESENCE SAINT JOSEPH HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 WEST NORTH AVENUE
CHICAGO IL
60610-0000
US

IV. Provider business mailing address

1000 REMINGTON BOULEVARD
BOLINGBROOK IL
60440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 312-337-1982
  • Fax: 312-642-3847
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELVONNE WICKLIFFE-JONES
Title or Position: CREDENTIALING MGR
Credential:
Phone: 630-914-2417