Basic Information
| Provider Information | |||||||||
| NPI: | 1205855707 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF WILMETTE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WILMETTE FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600900457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475778811 | ||||||||
| FaxNumber: | 8475777967 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WILMETTE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600911664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472512700 | ||||||||
| FaxNumber: | 8478537642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/27/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBBERSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8472512700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 8202 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 1632895 | 01 | IL | BCBS | OTHER | 590015238 | 01 | IL | RR MEDICARE | OTHER | 611708300 | 01 | IL | DOL OWCP | OTHER |