MEDICARE: RIDGE AMBULANCE SERVICE INC

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	7946	IL

General Provider Information

NPI Number	:	1275570061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIDGE AMBULANCE SERVICE INC

Provider Business Mailing Address
First Line	:	1851 AUCUTT RD
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1242
Country	:	US
Telephone Number	:	630-701-1198
Fax Number	:	630-859-2737

Provider Business Practice Location Address
First Line	:	1851 AUCUTT RD
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538
Country	:	US
Telephone Number	:	630-701-1198
Fax Number	:	630-859-2737

Authorized Official
Title or Position	:	PRESIDENT PARAMEDIC
Name	:	MR. RAYMOND DANIEL CALLAHAN
Credential	:
Telephone Number	:	630-898-2117

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	12/03/2019

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