=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730276734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERTS PARK FIRE PROTECTION DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 07/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8611 S ROBERTS RD
-----------------------------------------------------
City | JUSTICE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60458-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-598-6752
-----------------------------------------------------
Fax | 708-598-6778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 457
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60090-0457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-577-8811
-----------------------------------------------------
Fax | 847-577-3518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FIRE CHIEF
-----------------------------------------------------
Name | MR. WILLIAM DOHERTY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-598-6752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 78160
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------