Provider Demographics
NPI:1427005347
Name:BLACKHAWK MEDICAL TRANSPORTATION, INC.
Entity Type:Organization
Organization Name:BLACKHAWK MEDICAL TRANSPORTATION, INC.
Other - Org Name:VANDENBERG AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-532-1613
Mailing Address - Street 1:8400 183RD PL
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-9205
Mailing Address - Country:US
Mailing Address - Phone:708-532-1613
Mailing Address - Fax:
Practice Address - Street 1:8400 183RD PL
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-9268
Practice Address - Country:US
Practice Address - Phone:708-532-1613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMB TRAN GROUP, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL89593416L0300X
IL3459343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8100050OtherUNITED HEALTHCARE
IL0004598029OtherAETNA
IL0009932136OtherBLUE CROSS BLUE SHIELD
IL590013754OtherRAILROAD MEDICARE
IL590013754OtherRAILROAD MEDICARE
IL=========OtherUNICARE
IL=========001Medicaid