MEDICARE: CITY OF COUNTRY CLUB HILLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	78166	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00151630	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016-70820	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1265485007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF COUNTRY CLUB HILLS

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

Provider Business Practice Location Address
First Line	:	4200 W. 183RD ST
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-5311
Country	:	US
Telephone Number	:	708-798-8488
Fax Number	:	708-798-8555

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	MR. MICHELLE COON
Credential	:
Telephone Number	:	708-478-5694

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	12/10/2019

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Directions to “CITY OF COUNTRY CLUB HILLS ” Practice Location

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