Provider Demographics
NPI:1326123613
Name:CITY OF OFALLON
Entity Type:Organization
Organization Name:CITY OF OFALLON
Other - Org Name:OFALLON EMS
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-538-8278
Mailing Address - Street 1:285 N 7 HILLS RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-4110
Mailing Address - Country:US
Mailing Address - Phone:800-538-8278
Mailing Address - Fax:580-628-2273
Practice Address - Street 1:285 N 7 HILLS RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-4110
Practice Address - Country:US
Practice Address - Phone:800-538-8278
Practice Address - Fax:580-628-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL48653416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008220726OtherBCBS PROVIDER NUMBER
IL590009903OtherRRMC PROVIDER NUMBER
IL590009903OtherRRMC PROVIDER NUMBER
IL=========001Medicaid