Basic Information
Provider Information | |||||||||
NPI: | 1760579817 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VILLAGE OF WESTCHESTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 395 W LAKE ST | ||||||||
Address2: |   | ||||||||
City: | ELMHURST | ||||||||
State: | IL | ||||||||
PostalCode: | 601261508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6309032372 | ||||||||
FaxNumber: | 6309032830 | ||||||||
Practice Location | |||||||||
Address1: | 10240 W ROOSEVELT RD | ||||||||
Address2: |   | ||||||||
City: | WESTCHESTER | ||||||||
State: | IL | ||||||||
PostalCode: | 601542573 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083450433 | ||||||||
FaxNumber: | 7083450089 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2006 | ||||||||
LastUpdateDate: | 04/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NOSEK | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VILLAGE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7083450020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 88083 | IL | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 590007933 | 01 | IL | RAILROAD MEDICARE | OTHER | 01671551 | 01 | IL | BCBS | OTHER | 366006143001 | 05 | ID |   | MEDICAID |