Basic Information
| Provider Information | |||||||||
| NPI: | 1457370652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELBURN & COUNTRYSIDE FIRE PROTECTION DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELBURN AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ELBURN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601197000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303656855 | ||||||||
| FaxNumber: | 6303655887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | CALLAGHAN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 6303656855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7230 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 4532083 | 01 | IL | BCBS | OTHER | 590028268 | 01 | IL | RR MEDICARE | OTHER |