Provider Demographics
NPI:1285741033
Name:PRESENCE HEALTHCARE SERVICES PRESENCE MEDICAL GROUP
Entity type:Organization
Organization Name:PRESENCE HEALTHCARE SERVICES PRESENCE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REINHOLD
Authorized Official - Middle Name:
Authorized Official - Last Name:LLERENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-273-8908
Mailing Address - Street 1:1000 REMINGTON BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-0000
Mailing Address - Country:US
Mailing Address - Phone:630-914-2417
Mailing Address - Fax:630-914-2499
Practice Address - Street 1:4833 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2145
Practice Address - Country:US
Practice Address - Phone:773-205-2857
Practice Address - Fax:708-205-4380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095449Medicaid
745367Medicare PIN
IL704320Medicare ID - Type Unspecified
IL036095449Medicaid