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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	745367	OTHER	IL	MEDICARE PTAN

General Provider Information

NPI Number	:	1659650414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESURRECTION SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 564437
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-4437
Country	:	US
Telephone Number	:	708-583-7310
Fax Number	:	708-583-9870

Provider Business Practice Location Address
First Line	:	3814 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3807
Country	:	US
Telephone Number	:	773-522-5200
Fax Number	:	773-522-5356

Authorized Official
Title or Position	:	SR. VICE PRESIDENT
Name	:	DANIEL MC CORMICK
Credential	:
Telephone Number	:	708-583-6817

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/11/2011

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Directions to “RESURRECTION SERVICES ” Practice Location

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