MEDICARE: PRESENCE RESURRECTION MEDICAL CENTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01615536	OTHER		BLUE SHIELD PROVIDER #

General Provider Information

NPI Number	:	1124189139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESENCE RESURRECTION MEDICAL CENTER

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	:	7447 W TALCOTT
Second Line	:	SUITE 182
City	:	CHICAGO
State	:	IL
Zip	:	60631-0000
Country	:	US
Telephone Number	:	773-792-5155
Fax Number	:	630-914-2499

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	04/10/2013

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Directions to “PRESENCE RESURRECTION MEDICAL CENTER ” Practice Location

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