Basic Information
| Provider Information | |||||||||
| NPI: | 1750334504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOOD DALE FIRE PROTECTION DIST NO 1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 W LAKE ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305302372 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 589 N WOOD DALE RD | ||||||||
| Address2: | |||||||||
| City: | WOOD DALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601911535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307661147 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 6307731223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 97226 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 022-70502 | 01 | IL | BLUE CROSS BLUE SHILED | OTHER | 590013126 | 01 | IL | RAILROAD MEDICARE | OTHER |