Provider Demographics
NPI:1730133166
Name:TRACE AMBULANCE INC
Entity Type:Organization
Organization Name:TRACE AMBULANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:708-614-1343
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:708-614-1343
Mailing Address - Fax:708-570-1652
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:708-614-1343
Practice Address - Fax:708-633-1622
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMB TRAN GROUP, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL79493416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0099220355OtherBLUE CROSS BLUE SHIELD
IL0005110113OtherAETNA
IL590010440OtherRAILROAD MEDICARE
IL995737OtherUNITED HEALTHCARE
IL0005110113OtherAETNA
IL590010440OtherRAILROAD MEDICARE
IL=========001Medicaid
IL=========OtherHUMANA