Basic Information
| Provider Information | |||||||||
| NPI: | 1114196375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIESEKING | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | RICHMOND | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600900457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475778811 | ||||||||
| FaxNumber: | 8475773518 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ALTAMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624111402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184836821 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 09/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 510601 | IL | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 371199058002 | 05 | IL | MEDICAID |