=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437192556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHANY FIRE PROTECTION & AMBULANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 E MAIN STREET
-----------------------------------------------------
City | BETHANY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-665-3726
-----------------------------------------------------
Fax | 217-665-3932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 457
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60090-0457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-577-8811
-----------------------------------------------------
Fax | 847-577-9515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF
-----------------------------------------------------
Name | THOMAS RUCKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-665-3726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 6673901
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------