Basic Information
Provider Information
NPI: 1215038286
EntityType: 2
ReplacementNPI:  
OrganizationName: THUNDERBIRD FIRE PROTECTION TERRITORY
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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: 8475773518
Practice Location
Address1: 104 W HEAP ST
Address2:  
City: FARMERSBURG
State: IN
PostalCode: 47850
CountryCode: US
TelephoneNumber: 8126962151
FaxNumber: 8126962151
Other Information
ProviderEnumerationDate: 09/25/2006
LastUpdateDate: 10/10/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: QUILLIAM
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: FIRE CHIEF
AuthorizedOfficialTelephone: 8122498196
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix: JR.
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
3416L0300X1075INY Transportation ServicesAmbulanceLand Transport

ID Information
IDTypeStateIssuerDescription
00000038175601INBCBS ANTHEMOTHER


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