Healthcare Provider Details

I. General information

NPI: 1164780144
Provider Name (Legal Business Name): PRESENCE AMBULATORY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S NORTHWEST HWY SUITE 120
PARK RIDGE IL
60068-5802
US

IV. Provider business mailing address

1000 REMINGTON BLVD SUITE 100
BOLINGBROOK IL
60440-0000
US

V. Phone/Fax

Practice location:
  • Phone: 847-292-5200
  • Fax: 847-292-5239
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology 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