MEDICARE: CITY OF GRAYVILLE

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	5-51208	IL
2	3416L0300X	Land Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	590009587	OTHER	IL	RAILROAD
2	09730354	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1952351330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF GRAYVILLE

Provider Business Mailing Address
First Line	:	122 SOUTH COURT
Second Line	:
City	:	GRAYVILLE
State	:	IL
Zip	:	62844
Country	:	US
Telephone Number	:	618-375-3671
Fax Number	:	618-375-7869

Provider Business Practice Location Address
First Line	:	122 S COURT ST
Second Line	:
City	:	GRAYVILLE
State	:	IL
Zip	:	62844-1509
Country	:	US
Telephone Number	:	618-375-3671
Fax Number	:	618-375-7869

Authorized Official
Title or Position	:	PAYROLL CLERK
Name	:	CINDY ANNE JUDGE
Credential	:
Telephone Number	:	618-375-3671

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	09/15/2011

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Directions to “CITY OF GRAYVILLE ” Practice Location

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