Basic Information
| Provider Information | |||||||||
| NPI: | 1417184987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE OF GLEN ELLYN OFFICE OF TREAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 WEST LAKE STREET | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309032372 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | GLEN ELLYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601374137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304695265 | ||||||||
| FaxNumber: | 6304691762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | CAMBELL | ||||||||
| AuthorizedOfficialFirstName: | PETE | ||||||||
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| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 6304695265 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | IL2273 | 01 | IL | MEDICARE PART B | OTHER | 2234162 | 01 | IL | BCBS | OTHER |