Healthcare Provider Details

I. General information

NPI: 1548471535
Provider Name (Legal Business Name): PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 WEST DIVISION ST
CHICAGO IL
60622-3043
US

IV. Provider business mailing address

1000 REMINGTON BOULEVARD SUITE 100
BOLINGBROOK IL
60440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2050
  • Fax: 630-914-2499
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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