Provider Demographics
NPI:1386752525
Name:MAPLE PARK AND COUNTRYSIDE FIRE
Entity type:Organization
Organization Name:MAPLE PARK AND COUNTRYSIDE FIRE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-827-3500
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-0260
Mailing Address - Country:US
Mailing Address - Phone:815-539-2468
Mailing Address - Fax:815-539-6427
Practice Address - Street 1:305 S. COUNTYLINE ROAD
Practice Address - Street 2:
Practice Address - City:MAPLE PARK
Practice Address - State:IL
Practice Address - Zip Code:60151
Practice Address - Country:US
Practice Address - Phone:815-827-3500
Practice Address - Fax:815-827-3746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1 1018341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5032052OtherRAILROAD MEDICARE
IL05032052OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid
IL=========001Medicaid