Provider Demographics
NPI:1407984297
Name:COUNTY OF JOHNSON
Entity Type:Organization
Organization Name:COUNTY OF JOHNSON
Other - Org Name:JOHNSON COUNTY AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-658-2131
Mailing Address - Street 1:155 INDUSTRIAL DRIVE
Mailing Address - Street 2:P.O. BOX 38
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-0038
Mailing Address - Country:US
Mailing Address - Phone:618-658-2131
Mailing Address - Fax:618-658-8134
Practice Address - Street 1:155 INDUSTRIAL DRIVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-0038
Practice Address - Country:US
Practice Address - Phone:618-658-2131
Practice Address - Fax:618-658-8134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL550183416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL663550Medicare ID - Type Unspecified