Healthcare Provider Details

I. General information

NPI: 1730478454
Provider Name (Legal Business Name): RESURRECTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 E NORTHWEST HWY
MOUNT PROSPECT IL
60056-3464
US

IV. Provider business mailing address

PO BOX 564437
CHICAGO IL
60656-4437
US

V. Phone/Fax

Practice location:
  • Phone: 847-454-1001
  • Fax: 847-454-1002
Mailing address:
  • Phone: 708-583-7310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036056559
License Number StateIL

VIII. Authorized Official

Name: DANIEL MCCORMICK
Title or Position: SR VP
Credential: FACHE
Phone: 708-583-6817