Basic Information
| Provider Information | |||||||||
| NPI: | 1770540049 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANTIOCH RESCUE SQUAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600900457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475778811 | ||||||||
| FaxNumber: | 8475773518 | ||||||||
| Practice Location | |||||||||
| Address1: | 835 HOLBECK DR | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600021270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473950302 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | SOBCZAK | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | RESCUE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8473951010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 87264 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 049-21246 | 01 | IL | BCBS OF IL | OTHER | 590012429 | 01 | IL | RAILROAD MEDICARE | OTHER |