Basic Information
| Provider Information | |||||||||
| NPI: | 1730100942 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF BROADVIEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 WEST LAKE STREET | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309032372 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 S 25TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROADVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601553827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083436124 | ||||||||
| FaxNumber: | 7082048918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | KENNY | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7083436124 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 88055 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 590007932 | 01 | IL | RAILROAD MEDICARE | OTHER | 016-71276 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |