Basic Information
| Provider Information | |||||||||
| NPI: | 1174561591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF BUFFALO GROVE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BUFFALO GROVE FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 395 W LAKE ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309032381 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1051 HIGHLAND GROVE DR | ||||||||
| Address2: | |||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600897026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475370995 | ||||||||
| FaxNumber: | 8475377370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8477776100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 98179 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 07125772 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |