1841239217 NPI number — CITY OF CALUMET CITY

Table of content: (NPI 1841239217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841239217 NPI number — CITY OF CALUMET CITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF CALUMET CITY
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:
Provider Other Organization Name Type Code:
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:
1841239217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1053
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOKENA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60448-2052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-478-5694
Provider Business Mailing Address Fax Number:
708-478-5879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
684 WENTWORTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALUMET CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60409-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-891-8145
Provider Business Practice Location Address Fax Number:
708-891-3241
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BACHERT
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
708-891-8145

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  78164 , 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: 590005386 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2237310 . This is a "HARMONY WELLCARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1671109 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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