Basic Information
| Provider Information | |||||||||
| NPI: | 1225125362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF UNIVERSITY PARK | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 395 W LAKE ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305302988 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 698 BURNHAM DR | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604662708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082354833 | ||||||||
| FaxNumber: | 7085344820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | EXNER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7082354833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 77581 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 590004315 | 01 | IL | RAILROAD MEDICARE | OTHER | 09970769 | 01 | IL | BCBS | OTHER |