MEDICARE: BRAIDWOOD 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	3416L0300X	Land Ambulance	77151	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00166596	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	099-32200	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1801801782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAIDWOOD VOLUNTEER FIRE DEPARTMENT

Provider Business Mailing Address
First Line	:	395 WEST LAKE STREET
Second Line	:	ATTN: KIMBERLY FULLER
City	:	ELMHURST
State	:	IL
Zip	:	60126-1508
Country	:	US
Telephone Number	:	630-903-2372
Fax Number	:	630-903-2830

Provider Business Practice Location Address
First Line	:	275 W MAIN ST
Second Line	:
City	:	BRAIDWOOD
State	:	IL
Zip	:	60408-1919
Country	:	US
Telephone Number	:	815-458-2000
Fax Number	:	815-458-3636

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	KEN HEBERER
Credential	:
Telephone Number	:	815-458-2000

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	02/16/2012

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Directions to “BRAIDWOOD VOLUNTEER FIRE DEPARTMENT ” Practice Location

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