Provider Demographics
NPI:1134469752
Name:MEDIC 1
Entity Type:Organization
Organization Name:MEDIC 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-670-1221
Mailing Address - Street 1:9850 W 190TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-5604
Mailing Address - Country:US
Mailing Address - Phone:708-670-1221
Mailing Address - Fax:708-478-1628
Practice Address - Street 1:9850 W 190TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-5604
Practice Address - Country:US
Practice Address - Phone:708-670-1221
Practice Address - Fax:708-478-1628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAPPLIED FOR3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport