Basic Information
| Provider Information | |||||||||
| NPI: | 1841239217 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF CALUMET CITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1053 | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604482052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084785694 | ||||||||
| FaxNumber: | 7084785879 | ||||||||
| Practice Location | |||||||||
| Address1: | 684 WENTWORTH AVE | ||||||||
| Address2: | |||||||||
| City: | CALUMET CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604094241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088918145 | ||||||||
| FaxNumber: | 7088913241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BACHERT | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 7088918145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 78164 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 590005386 | 01 | IL | MEDICARE RAILROAD | OTHER | 2237310 | 01 | IL | HARMONY WELLCARE | OTHER | 1671109 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |