Basic Information
| Provider Information | |||||||||
| NPI: | 1316005978 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF JANESVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1446 N RANDALL AVENUE | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087587215 | ||||||||
| FaxNumber: | 6087583216 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087553000 | ||||||||
| FaxNumber: | 6087553196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WULF | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLERK & TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 6087553071 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic |
ID Information
| ID | Type | State | Issuer | Description | 41322800 | 05 | WI | MEDICAID |