Basic Information
| Provider Information | |||||||||
| NPI: | 1821003948 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF BEDFORD PARK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 6701 S ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605011936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085634513 | ||||||||
| FaxNumber: | 7085630295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MALOY | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7085634513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 78904 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 016-32352 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |