1265573612 NPI number — BRADFORD RESCUE SQUAD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265573612 NPI number — BRADFORD RESCUE SQUAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADFORD RESCUE SQUAD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265573612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40
Provider Second Line Business Mailing Address:
241 W MAIN STREET
Provider Business Mailing Address City Name:
BRADFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61421-0020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-682-5280
Provider Business Mailing Address Fax Number:
309-682-5327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
241 W MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61421-0040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-682-5280
Provider Business Practice Location Address Fax Number:
309-682-5327
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STOTLER
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-493-5112

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08832003 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00227106 . This is a "PALMETTO GBA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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