Basic Information
Provider Information | |||||||||
NPI: | 1790809887 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RESURRECTION SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RES-HEALTH CARDIOVASCULAR CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15330 S LA GRANGE RD | ||||||||
Address2: | SUITE 203 | ||||||||
City: | ORLAND PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 604623885 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7086758160 | ||||||||
FaxNumber: | 7083647474 | ||||||||
Practice Location | |||||||||
Address1: | 7411 WEST LAKE STREET | ||||||||
Address2: | SUITE 2110 | ||||||||
City: | RIVER FOREST | ||||||||
State: | IL | ||||||||
PostalCode: | 603051876 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7087632327 | ||||||||
FaxNumber: | 7084882380 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2007 | ||||||||
LastUpdateDate: | 10/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOBSON | ||||||||
AuthorizedOfficialFirstName: | DEAN | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7737973603 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 140049 | 01 | IL | MEDICARE GROUP NUMBER | OTHER | 1619414 | 01 |   | BCBS GRP | OTHER |