Basic Information
| Provider Information | |||||||||
| NPI: | 1033153325 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF SOUTH CHICAGO HEIGHTS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTH CHICAGO HEIGHTS FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1368 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305302988 | ||||||||
| FaxNumber: | 6308329750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3317 CHICAGO ROAD | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHICAGO HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604114815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087551880 | ||||||||
| FaxNumber: | 7087557186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VLIETSTRA | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7087559589 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 8923 | IL | N | Transportation Services | Ambulance | Land Transport | 3416L0300X | IL | N | Transportation Services | Ambulance | Land Transport | 341600000X | IL | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 9930119 | 01 | IL | BCBS | OTHER | 590013880 | 01 | IL | RR MEDICARE | OTHER |