Healthcare Provider Details

I. General information

NPI: 1922115864
Provider Name (Legal Business Name): PRESENCE HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 S STONY ISLAND AVE
CHICAGO IL
60617-3508
US

IV. Provider business mailing address

1000 REMINGTON BOULEVARD
BOLINGBROOK IL
60440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 773-731-0670
  • Fax: 773-731-1714
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209007288
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036053397
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036054086
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal 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