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Organization
PRESENCE SAINT JOSEPH HOSPITAL
Active
Organization
PRESENCE SAINT JOSEPH HOSPITAL
Active
Other names
LaBoure Outpatient
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MELVONNE WICKLIFFE-JONES (CREDENTIALING MGR)
(630) 914-2417
Entity
Organization
Contact information
Practice address
2900 NORTH LAKESHORE DRIVE, 1ST FLOOR CLINIC, CHICAGO, IL 60657-0000
(773) 665-3080
(773) 665-3498
Mailing address
1000 REMINGTON BOULEVARD, SUITE 100, BOLINGBROOK, IL 60440-0000
(630) 914-2417
(630) 914-2499
Taxonomy
Speciality
Code
Description
License number
State
207K00000X
Allergy & Immunology Physician
—
—
207N00000X
Dermatology Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
207RI0200X
Infectious Disease Physician
—
—
207RR0500X
Rheumatology Physician
—
—
207V00000X
Obstetrics & Gynecology Physician
—
—
207W00000X
Ophthalmology Physician
—
—
207Y00000X
Otolaryngology Physician
—
—
208000000X
Pediatrics Physician
—
—
2084P0800X
Psychiatry Physician
—
—
208600000X
Surgery Physician
—
—
208800000X
Urology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1632129
BCBS PROVIDER #
IL
Enumeration date
10/10/2006
Last updated
04/11/2013
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