MEDICARE: WATERMAN COMMUNITY 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	1011	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00360356	OTHER	IL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01932053	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1902839541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERMAN COMMUNITY FIRE PROTECTION DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX 260
Second Line	:
City	:	MENDOTA
State	:	IL
Zip	:	61342-0260
Country	:	US
Telephone Number	:	815-539-2468
Fax Number	:	815-539-6427

Provider Business Practice Location Address
First Line	:	160 NORTH CEDAR ST
Second Line	:
City	:	WATERMAN
State	:	IL
Zip	:	60556
Country	:	US
Telephone Number	:	815-264-3284
Fax Number	:	815-264-3284

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	EDWIN BOWMAN
Credential	:
Telephone Number	:	815-264-3284

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	04/26/2013

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