Basic Information
Provider Information | |||||||||
NPI: | 1730114091 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VILLAGE OF WINNETKA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WINNETKA FIRE DEPARTMENT | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 457 | ||||||||
Address2: |   | ||||||||
City: | WHEELING | ||||||||
State: | IL | ||||||||
PostalCode: | 600900457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475778811 | ||||||||
FaxNumber: | 8475777967 | ||||||||
Practice Location | |||||||||
Address1: | 428 GREEN BAY RD | ||||||||
Address2: |   | ||||||||
City: | WINNETKA | ||||||||
State: | IL | ||||||||
PostalCode: | 600932528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475016029 | ||||||||
FaxNumber: | 8474467989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 06/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
AuthorizedOfficialTelephone: | 8475016028 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 8203 | IL | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 590008158 | 01 | IL | RR MEDICARE | OTHER | 278740800 | 01 | IL | DOL OWCP | OTHER | 1671464 | 01 | IL | BCBS | OTHER |