1710055199 NPI number — CITY OF KEITHSBURG

Table of content: (NPI 1710055199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710055199 NPI number — CITY OF KEITHSBURG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF KEITHSBURG
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VOLUNTEER AMBULANCE SERVICE OF KEITHSBURG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710055199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEITHSBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61442-9627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-374-2414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 S 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEITHSBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61442-5033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-374-2220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
309-374-2414

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  000002555 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 362958288001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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