Healthcare Provider Details

I. General information

NPI: 1952748071
Provider Name (Legal Business Name): PRESENCE ST. MARY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W COURT ST
KANKAKEE IL
60901-3661
US

IV. Provider business mailing address

1000 REMINGTON BLVD SUITE 100
BOLINGBROOK IL
60440-5114
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-2200
  • Fax: 815-937-2258
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MELVONNE JONES
Title or Position: MGR, CREDENTIALING
Credential:
Phone: 630-914-2417