City of Country Club Hills

Primary specialty

Land AmbulanceTaxonomy code 3416L0300X

License

78166 Issued in IL

Legal business name

CITY OF COUNTRY CLUB HILLS

Practice address

4200 W. 183Rd St
Country Club Hills, IL 60478-5311

Phone

(708) 798-8488

Fax

(708) 798-8555

NPI assigned

May 19, 2006

Last updated

Dec 10, 2019By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Michelle Coon

Title

Fire Chief

Phone

(708) 478-5694

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1575936000000",
    "number": "1265485007",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1053",
            "city": "MOKENA",
            "state": "IL",
            "postal_code": "604482052",
            "telephone_number": "708-478-5694"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4200 W. 183RD ST",
            "city": "COUNTRY CLUB HILLS",
            "state": "IL",
            "postal_code": "604785311",
            "telephone_number": "708-798-8488",
            "fax_number": "708-798-8555"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CITY OF COUNTRY CLUB HILLS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2019-12-10",
        "certification_date": "2019-12-10",
        "status": "A",
        "authorized_official_last_name": "COON",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_title_or_position": "FIRE CHIEF",
        "authorized_official_telephone_number": "708-478-5694",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "3416L0300X",
            "taxonomy_group": "",
            "desc": "Ambulance, Land Transport",
            "state": "IL",
            "license": "78166",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "016-70820",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00151630",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Land Ambulance in Country Club Hills, IL
• Providers in Country Club Hills, IL by specialty
• Land Ambulance in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 10, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.