MEDICARE: CITY OF HIGHWOOD

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	107917	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04932568	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1376596148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF HIGHWOOD

Provider Business Mailing Address
First Line	:	395 W LAKE ST
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-1508
Country	:	US
Telephone Number	:	630-903-1280
Fax Number	:	630-903-2830

Provider Business Practice Location Address
First Line	:	428 GREEN BAY RD
Second Line	:
City	:	HIGHWOOD
State	:	IL
Zip	:	60040-1306
Country	:	US
Telephone Number	:	847-432-7622
Fax Number	:	847-432-7521

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	MR. THOMAS LOVEJOY
Credential	:
Telephone Number	:	847-432-7622

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	12/29/2011

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Directions to “CITY OF HIGHWOOD ” Practice Location

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