NPIMap

Organization Active NPI

Presence Healthcare Services

  • Internal Medicine Physician
  • Morton Grove, IL
National Provider Identifier
1699078238
Registry record updated Apr 10, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
PRESENCE HEALTHCARE SERVICES
Practice address
5747 West Dempster Street
Morton Grove, IL 60053-3056
Phone
(708) 324-8700
Fax
(847) 324-8705
NPI assigned
Dec 20, 2010
Last updated
Apr 10, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 10, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Melvonne Wickliffe-Jones
Title
Credentialing MGR
Phone
(630) 914-2417

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 036047645 IL
Internal Medicine Physician 207R00000X NU Primary

Addresses

Primary practice location

5747 West Dempster Street
Morton Grove, IL 60053-3056

Mailing address

1000 Remington Boulevard
Bolingbrook, IL 60440-0000
Phone (630) 914-2417

Other identifiers 2

IdentifierTypeStateIssuer
036047645MedicaidIL
036048363MedicaidIL

Other names 1

  • Presence Medical Group Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050215000965 IL Part B Supplier - Clinic/Group Practice 2860396769 Receives reassigned benefits from 128 practitioners
47 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 46

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 46

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1292803200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1365552000000",
    "number": "1699078238",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1000 REMINGTON BOULEVARD",
            "city": "BOLINGBROOK",
            "state": "IL",
            "postal_code": "604400000",
            "telephone_number": "630-914-2417",
            "fax_number": "630-914-2499"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5747 WEST DEMPSTER STREET",
            "city": "MORTON GROVE",
            "state": "IL",
            "postal_code": "600533056",
            "telephone_number": "708-324-8700",
            "fax_number": "847-324-8705"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRESENCE HEALTHCARE SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-12-20",
        "last_updated": "2013-04-10",
        "status": "A",
        "authorized_official_last_name": "WICKLIFFE-JONES",
        "authorized_official_first_name": "MELVONNE",
        "authorized_official_title_or_position": "CREDENTIALING MGR",
        "authorized_official_telephone_number": "630-914-2417",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IL",
            "license": "036047645",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036047645",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036048363",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Presence Medical Group",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Morton Grove, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.