Basic Information
| Provider Information | |||||||||
| NPI: | 1437192556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHANY FIRE PROTECTION & AMBULANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BETHANY FIRE PROTECTION DISTRICT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600900457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475778811 | ||||||||
| FaxNumber: | 8475779515 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 E MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176653726 | ||||||||
| FaxNumber: | 2176653932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 2176653726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 6673901 | IL | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 07032003 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 590015173 | 01 | IL | MEDICARE RAILROAD | OTHER |