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 State
1	261QR0200X	Radiology Clinic/Center	IL
2	261QR0206X	Mammography Clinic/Center	IL
3	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	917350	OTHER	IL	MEDICARE GROUP NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1638753	OTHER	IL	BCBS GRP

General Provider Information

NPI Number	:	1386767937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESURRECTION SERVICES

Provider Business Mailing Address
First Line	:	15330 S LA GRANGE RD
Second Line	:	SUITE 203
City	:	ORLAND PARK
State	:	IL
Zip	:	60462-3885
Country	:	US
Telephone Number	:	708-675-8160
Fax Number	:	708-364-7474

Provider Business Practice Location Address
First Line	:	3101 N HARLEM AVE
Second Line	:	RESURRECTION OPEN MRI IMAGING CENTER
City	:	CHICAGO
State	:	IL
Zip	:	60634-4532
Country	:	US
Telephone Number	:	773-836-9360
Fax Number	:	773-745-5522

Authorized Official
Title or Position	:	SYSTEM DIRECTOR
Name	:	DEAN M. HOBSON
Credential	:
Telephone Number	:	773-797-3603

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	10/30/2009

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Directions to “RESURRECTION SERVICES ” Practice Location

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