Basic Information
| Provider Information | |||||||||
| NPI: | 1295768364 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF SOUTH BELOIT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTH BELOIT FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 519 BLACKHAWK BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BELOIT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610801977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153893023 | ||||||||
| FaxNumber: | 8153898830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORSE | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8153893023 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 1416 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 590008426 | 01 | IL | RR MEDICARE | OTHER | 10119295 | 01 | IL | BCBS | OTHER |