Provider Demographics
NPI:1699078238
Name:PRESENCE HEALTHCARE SERVICES
Entity type:Organization
Organization Name:PRESENCE HEALTHCARE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKLIFFE-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-914-2417
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 1:5747 WEST DEMPSTER STREET
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-3056
Practice Address - Country:US
Practice Address - Phone:708-324-8700
Practice Address - Fax:847-324-8705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047645207R00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048363Medicaid
IL036047645Medicaid
745367Medicare PIN