Basic Information
| Provider Information | |||||||||
| NPI: | 1801801782 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRAIDWOOD VOLUNTEER FIRE DEPARTMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 WEST LAKE STREET | ||||||||
| Address2: | ATTN: KIMBERLY FULLER | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309032372 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRAIDWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604081919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154582000 | ||||||||
| FaxNumber: | 8154583636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | HEBERER | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8154582000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 77151 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | P00166596 | 01 | IL | RAILROAD MEDICARE | OTHER | 099-32200 | 01 | IL | BCBS | OTHER |