1760719546 NPI number — RESURRECTION AMBULATORY SERVICES

Table of content: (NPI 1760719546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760719546 NPI number — RESURRECTION AMBULATORY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESURRECTION AMBULATORY 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:
1760719546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15330 S LA GRANGE RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
ORLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60462-3885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-675-8160
Provider Business Mailing Address Fax Number:
708-364-7474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 WILLIAM ST
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
RIVER FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60305-1920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-488-2300
Provider Business Practice Location Address Fax Number:
708-488-2302
Provider Enumeration Date:
11/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HOBSON
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
SYSTEM DIRECTOR
Authorized Official Telephone Number:
773-797-3603

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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