1558479576 NPI number — THOMSON FIRE PROTECTION DIST AMBULANCE ASSOCIATION

Table of content: (NPI 1558479576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558479576 NPI number — THOMSON FIRE PROTECTION DIST AMBULANCE ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMSON FIRE PROTECTION DIST AMBULANCE ASSOCIATION
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:
6
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:
1558479576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOTA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61342-0260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-539-2468
Provider Business Mailing Address Fax Number:
815-539-6427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMSON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61285-8514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-259-8255
Provider Business Practice Location Address Fax Number:
815-259-8255
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IBEN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
815-259-2027

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  1 1019 , 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: P00246725 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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