Provider Demographics
NPI:1447308606
Name:CITY OF KENOSHA
Entity type:Organization
Organization Name:CITY OF KENOSHA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIVISION CHIEF OF EMS
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:POLTROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-653-4097
Mailing Address - Street 1:4810 60TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-2451
Mailing Address - Country:US
Mailing Address - Phone:262-653-4097
Mailing Address - Fax:262-653-4107
Practice Address - Street 1:4810 60TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-2451
Practice Address - Country:US
Practice Address - Phone:262-653-4097
Practice Address - Fax:262-653-4107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF KENOSHA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60004223416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI590005740OtherMEDICARE RAILROAD
WI590005740OtherMEDICARE RAILROAD
WI=========017OtherANTHEM BCBS
WI41358100Medicare ID - Type Unspecified