Basic Information
| Provider Information | |||||||||
| NPI: | 1043269038 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE OF WEST DUNDEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 WEST LAKE STREET | ||||||||
| Address2: | ATTN: KIMBERLY FULLER | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309032372 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CARRINGTON DR | ||||||||
| Address2: | |||||||||
| City: | WEST DUNDEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601181770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475513805 | ||||||||
| FaxNumber: | 8475513814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | FREISE | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8475513805 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 97134 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 045-23817 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 590010903 | 01 | IL | RAILROAD MEDICARE | OTHER |