Basic Information
Provider Information | |||||||||
NPI: | 1982635678 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VILLAGE OF SCHAUMBURG IL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SCHAUMBURG FIRE DEPARTMENT | ||||||||
OtherOrganizationType: | 4 | ||||||||
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: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 SCHAUMBURG CT | ||||||||
Address2: |   | ||||||||
City: | SCHAUMBURG | ||||||||
State: | IL | ||||||||
PostalCode: | 601931881 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478954500 | ||||||||
FaxNumber: | 8478957806 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 12/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALTERS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
AuthorizedOfficialTelephone: | 8478954500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/18/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 8132 | IL | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 1618202 | 01 | IL | BCBS | OTHER | 590012367 | 01 | IL | RR MEDICARE | OTHER |