Healthcare Provider Details

I. General information

NPI: 1427005347
Provider Name (Legal Business Name): BLACKHAWK MEDICAL TRANSPORTATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 183RD PL
TINLEY PARK IL
60477-9268
US

IV. Provider business mailing address

8400 183RD PL
TINLEY PARK IL
60487-9205
US

V. Phone/Fax

Practice location:
  • Phone: 708-532-1613
  • Fax:
Mailing address:
  • Phone: 708-532-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number8959
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number3459
License Number StateIL

VIII. Authorized Official

Name: MR. CHRISTOPHER J VANDENBERG
Title or Position: TREASURER
Credential:
Phone: 708-532-1613