MEDICARE: NORTHERN TAZEWELL RESCUE SQUAD

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	22582	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09032026	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1629113071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN TAZEWELL RESCUE SQUAD

Provider Business Mailing Address
First Line	:	2445 WASHINGTON RD
Second Line	:
City	:	WASHINGTON
State	:	IL
Zip	:	61571-1761
Country	:	US
Telephone Number	:	309-698-4700
Fax Number	:	309-698-7885

Provider Business Practice Location Address
First Line	:	2445 WASHINGTON RD
Second Line	:
City	:	WASHINGTON
State	:	IL
Zip	:	61571-1761
Country	:	US
Telephone Number	:	309-698-4700
Fax Number	:	309-698-7885

Authorized Official
Title or Position	:	TREASURER
Name	:	DAVID HOUSEWORTH
Credential	:
Telephone Number	:	309-698-4700

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	08/22/2020

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