Provider Demographics
NPI:1427118900
Name:ADVANCE EMS OF DIXON, INC.
Entity type:Organization
Organization Name:ADVANCE EMS OF DIXON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-288-6717
Mailing Address - Street 1:700 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3914
Mailing Address - Country:US
Mailing Address - Phone:815-288-4136
Mailing Address - Fax:815-288-2379
Practice Address - Street 1:700 COUNTRYSIDE LN
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3914
Practice Address - Country:US
Practice Address - Phone:815-288-6717
Practice Address - Fax:815-288-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1410341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid