Basic Information
| Provider Information | |||||||||
| NPI: | 1407872831 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTRYSIDE FIRE PROTECTION DIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 W LAKE ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309032381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 N DEERPATH DR | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473675511 | ||||||||
| FaxNumber: | 8473675521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8473675511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7273 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 132911900 | 01 | IL | DOL OWCP | OTHER | 4971120 | 01 | IL | BCBS | OTHER | 590013813 | 01 | IL | RR MEDICARE | OTHER |