MEDICARE: PRESENCE SAINT JOSEPH HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207K00000X	Allergy & Immunology Physician
2	207N00000X	Dermatology Physician
3	207RI0200X	Infectious Disease Physician
4	207RR0500X	Rheumatology Physician
5	207V00000X	Obstetrics & Gynecology Physician
6	207W00000X	Ophthalmology Physician
7	207Y00000X	Otolaryngology Physician
8	208000000X	Pediatrics Physician
9	2084P0800X	Psychiatry Physician
10	208600000X	Surgery Physician
11	208800000X	Urology Physician
12	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1632129	OTHER	IL	BCBS PROVIDER #

General Provider Information

NPI Number	:	1124116876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESENCE SAINT JOSEPH HOSPITAL

Provider Business Mailing Address
First Line	:	1000 REMINGTON BOULEVARD
Second Line	:	SUITE 100
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-0000
Country	:	US
Telephone Number	:	630-914-2417
Fax Number	:	630-914-2499

Provider Business Practice Location Address
First Line	:	2900 NORTH LAKESHORE DRIVE
Second Line	:	1ST FLOOR CLINIC
City	:	CHICAGO
State	:	IL
Zip	:	60657-0000
Country	:	US
Telephone Number	:	773-665-3080
Fax Number	:	773-665-3498

Authorized Official
Title or Position	:	CREDENTIALING MGR
Name	:	MRS. MELVONNE WICKLIFFE-JONES
Credential	:
Telephone Number	:	630-914-2417

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	04/11/2013

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Directions to “PRESENCE SAINT JOSEPH HOSPITAL ” Practice Location

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