1447308606 NPI number — CITY OF KENOSHA

Table of content: (NPI 1447308606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447308606 NPI number — CITY OF KENOSHA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF KENOSHA
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:
6
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:
1447308606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4810 60TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53144-2451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-653-4097
Provider Business Mailing Address Fax Number:
262-653-4107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4810 60TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53144-2451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-653-4097
Provider Business Practice Location Address Fax Number:
262-653-4107
Provider Enumeration Date:
01/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POLTROCK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
DIVISION CHIEF OF EMS
Authorized Official Telephone Number:
262-653-4097

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  6000422 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 590005740 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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