Basic Information
| Provider Information | |||||||||
| NPI: | 1710093372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF GURNEE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GURNEE FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6253 | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601976253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305302988 | ||||||||
| FaxNumber: | 6308329750 | ||||||||
| Practice Location | |||||||||
| Address1: | 4580 GRAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600312813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475996600 | ||||||||
| FaxNumber: | 8472448693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOSNELL | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8475997521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 107267 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 04920462 | 01 | IL | BCBS | OTHER | 590008355 | 01 | IL | RAILROAD MEDICARE | OTHER |