Basic Information
Provider Information | |||||||||
NPI: | 1497819684 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITY OF DESPLAINES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 438495 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606438495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732331170 | ||||||||
FaxNumber: | 7732338146 | ||||||||
Practice Location | |||||||||
Address1: | 405 S RIVER RD | ||||||||
Address2: |   | ||||||||
City: | DES PLAINES | ||||||||
State: | IL | ||||||||
PostalCode: | 600164730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732331170 | ||||||||
FaxNumber: | 7732338146 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 09/12/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WAX | ||||||||
AuthorizedOfficialFirstName: | ALAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
AuthorizedOfficialTelephone: | 7732331170 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 818001 | IL | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 132862900 | 01 | IL | U S DEPT OF LABOR | OTHER | 1636185 | 01 | IL | HMO ILLINOIS | OTHER | 1636185 | 01 | IL | BC BS OF ILLINOIS | OTHER |