Basic Information
| Provider Information | |||||||||
| NPI: | 1780698043 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOSEPH COUNTY - HARRIS CIVIL TOWNSHIP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARRIS CIVIL TOWNSHIP FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600900457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475778811 | ||||||||
| FaxNumber: | 8475777967 | ||||||||
| Practice Location | |||||||||
| Address1: | 13981 STATE ROAD 23 | ||||||||
| Address2: | |||||||||
| City: | GRANGER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465307596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742727861 | ||||||||
| FaxNumber: | 5742721108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANCE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 5742727861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 0433 | IN | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 000361043 | 01 | IN | ANTHEM BCBS | OTHER | 200103940A | 05 | IN | MEDICAID |