Provider Demographics
NPI:1962459834
Name:LIFE LINE EMERGENCY MEDICAL RESPONSE SERVICE CORP
Entity Type:Organization
Organization Name:LIFE LINE EMERGENCY MEDICAL RESPONSE SERVICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-997-4302
Mailing Address - Street 1:1003 WEST CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-997-4302
Mailing Address - Fax:618-997-5389
Practice Address - Street 1:1003 WEST CHERRY STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-997-4302
Practice Address - Fax:618-997-5389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL52223416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
610598100OtherFEDERAL WORKMAN COMP
IL10019731OtherBLUE CROSS BLUE SHIELD
590009057OtherRAILROAD MEDICARE
080893800OtherFEDERAL BLACK LUNG
080893800OtherFEDERAL BLACK LUNG
610598100OtherFEDERAL WORKMAN COMP
610598100OtherFEDERAL WORKMAN COMP