Provider Demographics
NPI:1063454379
Name:VILLAGE OF MUNDELEIN
Entity Type:Organization
Organization Name:VILLAGE OF MUNDELEIN
Other - Org Name:MUNDELEIN FIRE DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-623-6440
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-0457
Mailing Address - Country:US
Mailing Address - Phone:847-577-8811
Mailing Address - Fax:847-577-7967
Practice Address - Street 1:1000 N MIDLOTHIAN RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1235
Practice Address - Country:US
Practice Address - Phone:847-623-6440
Practice Address - Fax:847-623-9290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL72723416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932102OtherBCBS
IL590009421OtherRR MEDICARE
IL=========OtherTRICARE NORTH
IL=========001Medicaid
IL240100Medicare PIN
IL=========OtherTRICARE NORTH