1790064566 NPI number — PRESENCE HEALTHCARE SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790064566 NPI number — PRESENCE HEALTHCARE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESENCE HEALTHCARE 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:
Provider Other Organization Name Type Code:
6
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:
1790064566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 REMINGTON BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-914-2417
Provider Business Mailing Address Fax Number:
630-914-2499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 NORTH SHERIDAN ROAD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60657-6158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-248-8652
Provider Business Practice Location Address Fax Number:
773-248-8647
Provider Enumeration Date:
08/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WICKLIFFE-JONES
Authorized Official First Name:
MELVONNE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MGR
Authorized Official Telephone Number:
630-914-2417

Provider Taxonomy Codes

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

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





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