Basic Information
| Provider Information | |||||||||
| NPI: | 1942247093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEACH PARK FIRE DEPARTMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 W LAKE ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305301280 | ||||||||
| FaxNumber: | 6309032830 | ||||||||
| Practice Location | |||||||||
| Address1: | 3233 N LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | BEACH PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600872210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476622642 | ||||||||
| FaxNumber: | 8476622779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 12/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | TIERNEY | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8476622642 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7974 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | P0078980 | 01 | IL | MEDICARE RAILROAD | OTHER | 206946 | 01 | IL | MEDICARE, PART B | OTHER | 4932215 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |