Healthcare Provider Details

I. General information

NPI: 1235495631
Provider Name (Legal Business Name): RESURRECTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S NORTHWEST HWY SUITE 130
PARK RIDGE IL
60068-5802
US

IV. Provider business mailing address

62311 COLLECTION CENTER DR
CHICAGO IL
60693-0623
US

V. Phone/Fax

Practice location:
  • Phone: 847-292-5200
  • Fax:
Mailing address:
  • Phone: 800-273-2614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036080241
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036054785
License Number StateIL

VIII. Authorized Official

Name: DANIEL MCCORMICK
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 708-583-6817