1730282773 NPI number — RESURRECTION SERVICES

Table of content: (NPI 1730282773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730282773 NPI number — RESURRECTION SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESURRECTION SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RAYMOND MCDONALD, MD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730282773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 SUPERIOR ST
Provider Second Line Business Mailing Address:
STE 307
Provider Business Mailing Address City Name:
MELROSE PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60160-4138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-343-0079
Provider Business Mailing Address Fax Number:
708-343-2488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 SUPERIOR ST
Provider Second Line Business Practice Location Address:
STE 307
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60160-4138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-343-0079
Provider Business Practice Location Address Fax Number:
708-343-2488
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEDIC
Authorized Official First Name:
LEN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
708-583-6818

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 999100 . This is a "GROUP MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com