Basic Information
| Provider Information | |||||||||
| NPI: | 1326161340 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF BELOIT | ||||||||
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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: | 1111 CHURCH STREET | ||||||||
| Address2: | |||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642900 | ||||||||
| FaxNumber: | 6083642925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 04/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | LIGGETT | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 6083642902 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic |
ID Information
| ID | Type | State | Issuer | Description | 41329800 | 05 | WI | MEDICAID |