Provider Demographics
NPI:1568498079
Name:CITY OF BLOOMINGTON
Entity Type:Organization
Organization Name:CITY OF BLOOMINGTON
Other - Org Name:BLOOMINGTON FIRE DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-434-2500
Mailing Address - Street 1:310 N LEE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3834
Mailing Address - Country:US
Mailing Address - Phone:309-434-2500
Mailing Address - Fax:
Practice Address - Street 1:310 N LEE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3834
Practice Address - Country:US
Practice Address - Phone:309-434-2500
Practice Address - Fax:309-434-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid