Provider Demographics
NPI:1285653485
Name:CITY OF EAST PEORIA
Entity Type:Organization
Organization Name:CITY OF EAST PEORIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-698-4740
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 1:201 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2416
Practice Address - Country:US
Practice Address - Phone:309-698-4740
Practice Address - Fax:309-698-4725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL29683416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9020610OtherBCBS
IL690333345001Medicaid
IL9020610OtherBCBS
IL=========OtherTRICARE NORTH