MEDICARE: WAVERLY VOLUNTEER FIRE DEPARTMENT

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	EMS158956	IL

General Provider Information

NPI Number	:	1538418512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAVERLY VOLUNTEER FIRE DEPARTMENT

Provider Business Mailing Address
First Line	:	PO BOX 18
Second Line	:
City	:	WAVERLY
State	:	IL
Zip	:	62692-0018
Country	:	US
Telephone Number	:	217-435-2041
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 S PROSPECT ST
Second Line	:
City	:	WAVERLY
State	:	IL
Zip	:	62692-1168
Country	:	US
Telephone Number	:	217-435-2041
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	PAM GUTZMAN
Credential	:	EMT-B
Telephone Number	:	217-685-4722

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	01/07/2014

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Directions to “WAVERLY VOLUNTEER FIRE DEPARTMENT ” Practice Location

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