Healthcare Provider Details

I. General information

NPI: 1528051752
Provider Name (Legal Business Name): GALESBURG HOSPITALS' AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 WINDISH DR
GALESBURG IL
61401-9776
US

IV. Provider business mailing address

2175 WINDISH DR
GALESBURG IL
61401-9776
US

V. Phone/Fax

Practice location:
  • Phone: 309-342-5144
  • Fax: 309-342-4834
Mailing address:
  • Phone: 309-342-5144
  • Fax: 309-342-4834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number2603
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number022603
License Number StateIL

VIII. Authorized Official

Name: MICHAEL E WIGNALL
Title or Position: ACCOUNTANT
Credential:
Phone: 309-342-5144