Provider Demographics
NPI:1184669822
Name:GILLESPIE-BENLD AREA AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:GILLESPIE-BENLD AREA AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:NORVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-839-3032
Mailing Address - Street 1:208 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033-2117
Mailing Address - Country:US
Mailing Address - Phone:217-839-3032
Mailing Address - Fax:217-839-3053
Practice Address - Street 1:208 CHARLES ST
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-2117
Practice Address - Country:US
Practice Address - Phone:217-839-3032
Practice Address - Fax:217-839-3053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL30103416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA590004529OtherRR MEDICARE
GA590004529OtherRR MEDICARE
IL=========001Medicaid