Provider Demographics
NPI:1427186584
Name:VILLAGE OF PEORIA HEIGHTS
Entity Type:Organization
Organization Name:VILLAGE OF PEORIA HEIGHTS
Other - Org Name:PEORIA HEIGHTS AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AMBULANCE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MAROTTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-686-2386
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:847-577-3518
Practice Address - Street 1:4901 N PROSPECT RD
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-5397
Practice Address - Country:US
Practice Address - Phone:309-686-2370
Practice Address - Fax:309-682-3089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225723416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590006195OtherRAILROAD MEDICARE
ID07232092OtherBLUE CROSS BLUE SHIELD
IL590006195OtherRAILROAD MEDICARE
ID07232092OtherBLUE CROSS BLUE SHIELD