Provider Demographics
NPI:1972046746
Name:COLEMAN, RONALD THOMAS SR
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:THOMAS
Last Name:COLEMAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16656 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2842
Mailing Address - Country:US
Mailing Address - Phone:773-808-0673
Mailing Address - Fax:708-893-0550
Practice Address - Street 1:16656 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2842
Practice Address - Country:US
Practice Address - Phone:773-808-0673
Practice Address - Fax:708-893-0550
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILC45573861092343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)