Basic Information
| Provider Information | |||||||||
| NPI: | 1467517219 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF FLOSSMOOR | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 438495 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606438495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732331170 | ||||||||
| FaxNumber: | 7732338146 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 FLOSSMOOR RD | ||||||||
| Address2: | |||||||||
| City: | FLOSSMOOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604221156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732331170 | ||||||||
| FaxNumber: | 7732338146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEWELL | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7732331170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | IL | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 590001449 | 01 | IL | RAILROAD RETIREMENT | OTHER | 1670560 | 01 | IL | BC BS OF ILLINOIS | OTHER | 1670560 | 01 | IL | HMO ILLINOIS | OTHER |