Provider Demographics
NPI:1558444828
Name:BLOOMFIELD GENOA CITY FIRE & RESCUE
Entity Type:Organization
Organization Name:BLOOMFIELD GENOA CITY FIRE & RESCUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:POLTERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-279-2033
Mailing Address - Street 1:395 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1508
Mailing Address - Country:US
Mailing Address - Phone:630-530-2988
Mailing Address - Fax:630-903-2830
Practice Address - Street 1:N 1113 CLOVER RD.
Practice Address - Street 2:
Practice Address - City:PELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:53157
Practice Address - Country:US
Practice Address - Phone:262-279-2033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60012233416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI396005800001Medicaid
WI39600580018OtherBCBS