Basic Information
| Provider Information | |||||||||
| NPI: | 1396032462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RESURRECTION SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 564437 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606564437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085837310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 N LAKE SHORE DR | ||||||||
| Address2: | SUITE 1208 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736654964 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2011 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7085836817 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 036109067 | 05 | IL | MEDICAID |