Basic Information
| Provider Information | |||||||||
| NPI: | 1245393073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY OF BERWYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1368 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601268368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305302988 | ||||||||
| FaxNumber: | 6308329750 | ||||||||
| Practice Location | |||||||||
| Address1: | 6700 26TH ST | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604022500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087882660 | ||||||||
| FaxNumber: | 7087883990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7087496474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 805401 | IL | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 000026648 | 01 | WI | MEDICAID PROVIDER, WISC. | OTHER | 1670585 | 01 | IL | BC BS PROVIDER NUMBER | OTHER | 1670585 | 01 | IL | HMO ILLINOIS | OTHER | 590004104 | 01 | IL | RAILROAD RETIREMENT # | OTHER |