Basic Information
| Provider Information | |||||||||
| NPI: | 1659392850 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE OF GLENCOE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 W LAKE ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305301280 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 VILLAGE CT | ||||||||
| Address2: | |||||||||
| City: | GLENCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600221609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478354112 | ||||||||
| FaxNumber: | 8478358438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEWANDOWSKI | ||||||||
| AuthorizedOfficialFirstName: | CARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PUBLIC SAFETY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8474611132 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 108915 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 016-19842 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 590011314 | 01 | IL | RAILROAD MEDICARE | OTHER | 366085899001 | 05 | IL | MEDICAID |