MEDICARE: PRESENCE HEALTHCARE 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	363LF0000X	Family Nurse Practitioner	209007288	IL
2	207R00000X	Internal Medicine Physician	036053397	IL
3	207R00000X	Internal Medicine Physician	036054086	IL
4	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	209007288	OTHER	IL	STATE LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922115864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESENCE HEALTHCARE SERVICES

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	:	9000 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-3508
Country	:	US
Telephone Number	:	773-731-0670
Fax Number	:	773-731-1714

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

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	04/10/2013

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Directions to “PRESENCE HEALTHCARE SERVICES ” Practice Location

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