Provider Demographics
NPI:1245224138
Name:ELIZABETH COMMUNITY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:ELIZABETH COMMUNITY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:E
Authorized Official - Middle Name:RUDY
Authorized Official - Last Name:PASCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-858-2404
Mailing Address - Street 1:111 E MYRTLE ST
Mailing Address - Street 2:P O BOX 325
Mailing Address - City:ELIZABETH
Mailing Address - State:IL
Mailing Address - Zip Code:61028-9794
Mailing Address - Country:US
Mailing Address - Phone:815-858-2404
Mailing Address - Fax:
Practice Address - Street 1:111 E MYRTLE ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:IL
Practice Address - Zip Code:61028-9794
Practice Address - Country:US
Practice Address - Phone:815-858-2404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15950133416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL609170Medicare ID - Type UnspecifiedMEDICARE