Basic Information
Provider Information | |||||||||
NPI: | 1063454379 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VILLAGE OF MUNDELEIN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MUNDELEIN FIRE DEPARTMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 457 | ||||||||
Address2: |   | ||||||||
City: | WHEELING | ||||||||
State: | IL | ||||||||
PostalCode: | 600900457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475778811 | ||||||||
FaxNumber: | 8475777967 | ||||||||
Practice Location | |||||||||
Address1: | 1000 N MIDLOTHIAN RD | ||||||||
Address2: |   | ||||||||
City: | MUNDELEIN | ||||||||
State: | IL | ||||||||
PostalCode: | 600601235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476236440 | ||||||||
FaxNumber: | 8476239290 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 06/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JUSTUS | ||||||||
AuthorizedOfficialFirstName: | RANDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
AuthorizedOfficialTelephone: | 8476236440 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7272 | IL | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 4932102 | 01 | IL | BCBS | OTHER | 590009421 | 01 | IL | RR MEDICARE | OTHER |