Provider Demographics
NPI:1295809739
Name:MVK AMBULANCE SERVICE
Entity type:Organization
Organization Name:MVK AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-448-2134
Mailing Address - Street 1:PO BOX 316
Mailing Address - Street 2:
Mailing Address - City:MAZON
Mailing Address - State:IL
Mailing Address - Zip Code:60444-0316
Mailing Address - Country:US
Mailing Address - Phone:815-448-2134
Mailing Address - Fax:
Practice Address - Street 1:604 FRONT ST
Practice Address - Street 2:
Practice Address - City:MAZON
Practice Address - State:IL
Practice Address - Zip Code:60444
Practice Address - Country:US
Practice Address - Phone:815-448-2134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL792201341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3221361OtherBLUE CROSS BLUE SHIELD
IL3221361OtherBLUE CROSS BLUE SHIELD
IL3221361OtherBLUE CROSS BLUE SHIELD