Basic Information
| Provider Information | |||||||||
| NPI: | 1639393184 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF LAKEWOOD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKEWOOD FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600900457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475778811 | ||||||||
| FaxNumber: | 8475773518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | VILLAGE OF LAKEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600145120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154593025 | ||||||||
| FaxNumber: | 8154593156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEUMANN | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8154593025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 8205 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 5632233 | 01 | IL | BCBS | OTHER |