MEDICARE: STEPHEN & FRED SHRADER PTR

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	341600000X	Ambulance	670002	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2190002	OTHER	IL	BCBS NUMBER

General Provider Information

NPI Number	:	1366599854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEPHEN & FRED SHRADER PTR

Provider Business Mailing Address
First Line	:	PO BOX 277
Second Line	:	204 N. LOCUST ST
City	:	ARCOLA
State	:	IL
Zip	:	61910-0277
Country	:	US
Telephone Number	:	217-268-4848
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 N LOCUST ST
Second Line	:
City	:	ARCOLA
State	:	IL
Zip	:	61910-1407
Country	:	US
Telephone Number	:	217-268-4848
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. CONNIE SHRADER
Credential	:
Telephone Number	:	217-268-4848

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	01/24/2012

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