Provider Demographics
NPI:1710055199
Name:CITY OF KEITHSBURG
Entity Type:Organization
Organization Name:CITY OF KEITHSBURG
Other - Org Name:VOLUNTEER AMBULANCE SERVICE OF KEITHSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-374-2414
Mailing Address - Street 1:601 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:KEITHSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61442-9627
Mailing Address - Country:US
Mailing Address - Phone:309-374-2414
Mailing Address - Fax:
Practice Address - Street 1:202 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KEITHSBURG
Practice Address - State:IL
Practice Address - Zip Code:61442-5033
Practice Address - Country:US
Practice Address - Phone:309-374-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000025553416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362958288001Medicaid
IL631600Medicare ID - Type UnspecifiedMEDICARE