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	207V00000X	Obstetrics & Gynecology Physician
2	208000000X	Pediatrics Physician
3	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1633408	OTHER	IL	BLUE CROSS/BLUE SHIELD #

General Provider Information

NPI Number	:	1366537953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESENCE SAINT JOSEPH HOSPITAL

Provider Business Mailing Address
First Line	:	1000 REMINGTON BOULEVARD
Second Line	:
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	:	711 WEST NORTH AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-0000
Country	:	US
Telephone Number	:	312-337-1982
Fax Number	:	312-642-3847

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	04/09/2013

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Directions to “PRESENCE SAINT JOSEPH HOSPITAL ” Practice Location

Language	Start Address	Practice Location

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