Provider Demographics
NPI:1730243569
Name:CITY OF BLUE ISLAND
Entity type:Organization
Organization Name:CITY OF BLUE ISLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-606-6736
Mailing Address - Street 1:PO BOX 1053
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2052
Mailing Address - Country:US
Mailing Address - Phone:708-478-5694
Mailing Address - Fax:
Practice Address - Street 1:2450 VERMONT ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2362
Practice Address - Country:US
Practice Address - Phone:773-233-1170
Practice Address - Fax:773-233-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL815701341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1636216OtherBC BS OF ILLINOIS
IL132857300OtherU.S. DEPT OF LABOR
ILL027264OtherCHAMPUS
IL1636216OtherHMO ILLINOIS
IL1636216OtherBC BS OF ILLINOIS
IL=========001Medicaid