Provider Demographics
NPI:1972518686
Name:CITY OF LAKE FOREST
Entity type:Organization
Organization Name:CITY OF LAKE FOREST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-810-3864
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-0457
Mailing Address - Country:US
Mailing Address - Phone:847-577-8811
Mailing Address - Fax:847-577-7967
Practice Address - Street 1:255 W DEERPATH RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2104
Practice Address - Country:US
Practice Address - Phone:847-615-4243
Practice Address - Fax:847-615-4382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL72693416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4922101OtherBCBS
IL216269300OtherDOL OWCP
IL=========OtherTRICARE NORTH
IL=========001Medicaid
IL=========001Medicaid
IL4922101OtherBCBS