Basic Information
| Provider Information | |||||||||
| NPI: | 1922121599 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RESURRECTION SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RESURRECTION IMMEDIATE CARE CENTER NORRIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 4900 CUMBERLAND | ||||||||
| Address2: | RESURRECTION IMMEDIATE CARE CENTER NORRIDGE | ||||||||
| City: | NORRIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607062916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084561600 | ||||||||
| FaxNumber: | 7084632781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | HOBSON | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7737973603 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1619414 | 01 | IL | BCBS GRP | OTHER |