MEDICARE: RESURRECTION SERVICES

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	207R00000X	Internal Medicine Physician		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	211982	OTHER	IL	MEDICARE GROUP

General Provider Information

NPI Number	:	1205943107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESURRECTION SERVICES

Provider Business Mailing Address
First Line	:	5113 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2807
Country	:	US
Telephone Number	:	773-271-2050
Fax Number	:	773-271-0911

Provider Business Practice Location Address
First Line	:	5113 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2807
Country	:	US
Telephone Number	:	773-271-2050
Fax Number	:	773-271-0911

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	LEN DEDIC
Credential	:
Telephone Number	:	708-583-6818

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	10/26/2007

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Directions to “RESURRECTION SERVICES ” Practice Location

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