Provider Demographics
NPI:1487735510
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:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-583-6818
Mailing Address - Street 1:2246 W. CHICAGO AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622
Mailing Address - Country:US
Mailing Address - Phone:773-276-6831
Mailing Address - Fax:773-276-9394
Practice Address - Street 1:2246 W. CHICAGO AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-276-6831
Practice Address - Fax:773-276-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
214696OtherMEDICARE GROUP