Healthcare Provider Details

I. General information

NPI: 1760701841
Provider Name (Legal Business Name): PRESENCE HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5308 NORTH BELMONT AVENUE
CHICAGO IL
60641-0000
US

IV. Provider business mailing address

1000 REMINGTON BOULEVARD
BOLINGBROOK IL
60440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 773-427-8114
  • Fax: 773-472-8116
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036121746
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

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