Basic Information
| Provider Information | |||||||||
| NPI: | 1124116876 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESENCE SAINT JOSEPH HOSPITAL | ||||||||
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| OtherOrganizationName: | LABOURE OUTPATIENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BOULEVARD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604400000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309142417 | ||||||||
| FaxNumber: | 6309142499 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 NORTH LAKESHORE DRIVE | ||||||||
| Address2: | 1ST FLOOR CLINIC | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606570000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653080 | ||||||||
| FaxNumber: | 7736653498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 04/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | WICKLIFFE-JONES | ||||||||
| AuthorizedOfficialFirstName: | MELVONNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MGR | ||||||||
| AuthorizedOfficialTelephone: | 6309142417 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1632129 | 01 | IL | BCBS PROVIDER # | OTHER |