MEDICARE: CITY OF GRANITE CITY

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	001	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0006070059	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1538139209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF GRANITE CITY

Provider Business Mailing Address
First Line	:	PO BOX 457
Second Line	:
City	:	WHEELING
State	:	IL
Zip	:	60090-0457
Country	:	US
Telephone Number	:	847-577-8811
Fax Number	:	847-577-3518

Provider Business Practice Location Address
First Line	:	2300 MADISON AVE
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4750
Country	:	US
Telephone Number	:	618-452-6231
Fax Number	:	618-452-6232

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	MR. TIMOTHY JAMES CONNOLLY
Credential	:
Telephone Number	:	618-452-6231

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/21/2022

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Directions to “CITY OF GRANITE CITY ” Practice Location

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