Basic Information
| Provider Information | |||||||||
| NPI: | 1366434821 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEROMESVILLE FIRE DISTRICT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 951953 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376193013 | ||||||||
| FaxNumber: | 9376193014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | JEROMESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448409783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193686811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FULK | ||||||||
| AuthorizedOfficialFirstName: | MAX | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 4193686811 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | OH | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 2553811 | 05 | OH | MEDICAID | 000000155551 | 01 | OH | ANTHEM | OTHER |