Provider Demographics
NPI:1760489199
Name:CITY OF MOLINE
Entity Type:Organization
Organization Name:CITY OF MOLINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:LUVERNE
Authorized Official - Last Name:SEDERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-524-2257
Mailing Address - Street 1:1630 8TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-2116
Mailing Address - Country:US
Mailing Address - Phone:309-524-2250
Mailing Address - Fax:309-524-2270
Practice Address - Street 1:1630 8TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-2116
Practice Address - Country:US
Practice Address - Phone:309-524-2250
Practice Address - Fax:309-524-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22537341600000X
IL02253702341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590918082OtherRR MEDICARE
IA0977744Medicaid
211970Medicare PIN
IL211970Medicare ID - Type Unspecified