Provider Demographics
NPI:1124135181
Name:RESURRECTION SERVICES
Entity type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-583-6818
Mailing Address - Street 1:10015 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2546
Mailing Address - Country:US
Mailing Address - Phone:847-451-0643
Mailing Address - Fax:847-451-0792
Practice Address - Street 1:10015 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-2546
Practice Address - Country:US
Practice Address - Phone:847-451-0643
Practice Address - Fax:847-451-0792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH08058Medicare UPIN
IL212961Medicare ID - Type Unspecified