Basic Information
| Provider Information | |||||||||
| NPI: | 1205110855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESENCE HEALTHCCARE SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRESENCE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62311 COLLECTION CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606930623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309142417 | ||||||||
| FaxNumber: | 6309142469 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 N SHERIDAN RD | ||||||||
| Address2: | STE 506 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606576156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734727680 | ||||||||
| FaxNumber: | 7734727697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2011 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | LLERENA | ||||||||
| AuthorizedOfficialFirstName: | REINHOLD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2242738908 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.