MEDICARE: SOUTH PARK FIRE PROTECTION DISTRICT

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	7234	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4521008	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1841233012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PARK FIRE PROTECTION DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX 457
Second Line	:
City	:	WHEELING
State	:	IL
Zip	:	60090-0457
Country	:	US
Telephone Number	:	847-577-8811
Fax Number	:	847-577-7967

Provider Business Practice Location Address
First Line	:	599 MONTGOMERY RD
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1729
Country	:	US
Telephone Number	:	630-898-3222
Fax Number	:	630-898-3221

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	KURT DELLES
Credential	:
Telephone Number	:	630-898-3222

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	04/20/2008

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Directions to “SOUTH PARK FIRE PROTECTION DISTRICT ” Practice Location

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