Provider Demographics
NPI:1952466815
Name:VILLAGE OF MERRIONETTE PARK
Entity Type:Organization
Organization Name:VILLAGE OF MERRIONETTE PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MS
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:EDLING
Authorized Official - Suffix:
Authorized Official - Credentials:EMT
Authorized Official - Phone:773-233-1170
Mailing Address - Street 1:PO BOX 1053
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2052
Mailing Address - Country:US
Mailing Address - Phone:708-478-5694
Mailing Address - Fax:
Practice Address - Street 1:11720 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-4516
Practice Address - Country:US
Practice Address - Phone:773-233-1170
Practice Address - Fax:773-233-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL891001341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1636180OtherHMO ILLINOIS
IL1636180OtherBC BS OF ILLINOIS
IL590009584OtherRAILROAD RETIREMENT
IL1636180OtherHMO ILLINOIS
IL=========001Medicaid