1700871910 NPI number — FORMAN AMBULANCE SERVICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700871910 NPI number — FORMAN AMBULANCE SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORMAN AMBULANCE SERVICE
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:
1700871910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 648
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANITO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61546-0648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-968-6902
Provider Business Mailing Address Fax Number:
309-968-6649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 N BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANITO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61546-0648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-968-6902
Provider Business Practice Location Address Fax Number:
309-968-6649
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BORTELL
Authorized Official First Name:
SHERON
Authorized Official Middle Name:
KAYE
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
309-968-6902

Provider Taxonomy Codes

  • Taxonomy code: 3416A0800X , with the licence number:  1660298 , 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: 237154244001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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