MEDICARE: CITY OF CALUMET CITY

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	78164	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	590005386	OTHER	IL	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	2237310	OTHER	IL	HARMONY WELLCARE
3	1671109	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1841239217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF CALUMET CITY

Provider Business Mailing Address
First Line	:	PO BOX 1053
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-2052
Country	:	US
Telephone Number	:	708-478-5694
Fax Number	:	708-478-5879

Provider Business Practice Location Address
First Line	:	684 WENTWORTH AVE
Second Line	:
City	:	CALUMET CITY
State	:	IL
Zip	:	60409-4241
Country	:	US
Telephone Number	:	708-891-8145
Fax Number	:	708-891-3241

Authorized Official
Title or Position	:	CHIEF
Name	:	GLENN BACHERT
Credential	:
Telephone Number	:	708-891-8145

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	12/06/2019

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Directions to “CITY OF CALUMET CITY ” Practice Location

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