Provider Demographics
NPI:1265573612
Name:BRADFORD RESCUE SQUAD
Entity type:Organization
Organization Name:BRADFORD RESCUE SQUAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:STOTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-493-5112
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:241 W MAIN STREET
Mailing Address - City:BRADFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61421-0020
Mailing Address - Country:US
Mailing Address - Phone:309-682-5280
Mailing Address - Fax:309-682-5327
Practice Address - Street 1:241 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:IL
Practice Address - Zip Code:61421-0040
Practice Address - Country:US
Practice Address - Phone:309-682-5280
Practice Address - Fax:309-682-5327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08832003OtherBLUE CROSS
ILP00227106OtherPALMETTO GBA
IL=========001Medicaid
IL08832003OtherBLUE CROSS