Provider Demographics
NPI:1023219094
Name:TRI DISTRICT EMERGENCY AMBULANCE
Entity type:Organization
Organization Name:TRI DISTRICT EMERGENCY AMBULANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOELLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-865-5153
Mailing Address - Street 1:P.O. BOX 117
Mailing Address - Street 2:7563 IL ROUTE 75
Mailing Address - City:ROCK CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61070-0117
Mailing Address - Country:US
Mailing Address - Phone:815-865-5153
Mailing Address - Fax:815-865-5153
Practice Address - Street 1:7563 IL ROUTE 75
Practice Address - Street 2:
Practice Address - City:ROCK CITY
Practice Address - State:IL
Practice Address - Zip Code:61070-0117
Practice Address - Country:US
Practice Address - Phone:815-865-5153
Practice Address - Fax:815-865-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
146M00000X
IL01103601146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Single Specialty
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL643640Medicare PIN