Provider Demographics
NPI:1720194970
Name:JEFFERSON TWP TTEES
Entity Type:Organization
Organization Name:JEFFERSON TWP TTEES
Other - Org Name:JEFFERSON TOWNSHIP FIRE DEPT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-453-2571
Mailing Address - Street 1:10361 SPARTAN DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1220
Mailing Address - Country:US
Mailing Address - Phone:800-962-1484
Mailing Address - Fax:513-772-4464
Practice Address - Street 1:3188 MAYSVILLE ST
Practice Address - Street 2:
Practice Address - City:BOWERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45307
Practice Address - Country:US
Practice Address - Phone:937-453-2571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0212634503416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000494050OtherANTHEM
OH2698808Medicaid
OH=========OtherTRICARE 4 LIFE
OH=========00OtherBUREAU OF WORKERS COMP
000000494050OtherANTHEM
000000494050OtherANTHEM