MEDICARE: CENTRAL STICKNEY FIRE PROTECTION

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1636184	OTHER	IL	HMO ILLINOIS
2	1636184	OTHER	IL	BC BS OF ILLINOIS
3	590009208	OTHER	IL	RAILROAD RETIREMENT

General Provider Information

NPI Number	:	1770648271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL STICKNEY FIRE PROTECTION

Provider Business Mailing Address
First Line	:	PO BOX 438495
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-8495
Country	:	US
Telephone Number	:	773-233-1170
Fax Number	:	773-233-8146

Provider Business Practice Location Address
First Line	:	4951 S LOTUS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-1719
Country	:	US
Telephone Number	:	773-233-1170
Fax Number	:	773-233-8146

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	BRIAN MCMAHON
Credential	:
Telephone Number	:	773-233-1170

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	01/30/2012

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