Provider Demographics
NPI:1689748139
Name:GARDNER VOLUNTEER FIRE DEPARTMENT
Entity type:Organization
Organization Name:GARDNER VOLUNTEER FIRE DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-237-8806
Mailing Address - Street 1:35 E WILLOW ST STE B
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1869
Mailing Address - Country:US
Mailing Address - Phone:815-634-3048
Mailing Address - Fax:815-634-3188
Practice Address - Street 1:206 DEPOT STREET
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:IL
Practice Address - Zip Code:60424
Practice Address - Country:US
Practice Address - Phone:815-237-8806
Practice Address - Fax:815-237-0066
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
IL77819341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00154114OtherRAILROAD MEDICARE
IL332002OtherBLUE CROSS BLUE SHIELD
ILP00154114OtherRAILROAD MEDICARE
P00154114OtherRAILROAD MEDICARE
ILP00154114OtherRAILROAD MEDICARE