Basic Information
| Provider Information | |||||||||
| NPI: | 1396800892 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF EVERGREEN PARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1053 | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604482052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084785694 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9000 S KEDZIE AVE | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608051311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732331170 | ||||||||
| FaxNumber: | 7732338146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 12/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | KLEINHAUS | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7732331170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/10/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | IL | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 1670314 | 01 | IL | HMO ILLINOIS | OTHER | 1670314 | 01 | IL | BC BS OF ILLINOIS | OTHER | 590001810 | 01 | IL | RAILROAD RETIREMENT | OTHER |