Provider Demographics
NPI:1619036829
Name:OSF LIFELINE AMBULANCE, LLC
Entity Type:Organization
Organization Name:OSF LIFELINE AMBULANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-655-2850
Mailing Address - Street 1:PO BOX 17115
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-7115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:318 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5090
Practice Address - Country:US
Practice Address - Phone:815-395-4695
Practice Address - Fax:805-395-4643
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSF HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL471203OtherBLUE CROSS
IL471203OtherBLUE CROSS
IL=========001Medicaid
IL207199Medicare PIN