Provider Demographics
NPI:1881679678
Name:EVERGREEN EMERGENCY SERVICES, LTD
Entity Type:Organization
Organization Name:EVERGREEN EMERGENCY SERVICES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-422-4221
Mailing Address - Street 1:PO BOX 42898
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-0898
Mailing Address - Country:US
Mailing Address - Phone:708-422-4221
Mailing Address - Fax:708-422-4415
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2701
Practice Address - Country:US
Practice Address - Phone:708-422-4221
Practice Address - Fax:708-422-4415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL369320Medicare PIN