Basic Information
| Provider Information | |||||||||
| NPI: | 1811229693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | SAINTS MARY AND ELIZABETH MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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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: | 1431 N WESTERN AVE | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123322226 | ||||||||
| FaxNumber: | 7732761197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2010 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | WICKLIFFE-JONES | ||||||||
| AuthorizedOfficialFirstName: | MELVONNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MGR | ||||||||
| AuthorizedOfficialTelephone: | 6309142417 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.