Basic Information
| Provider Information | |||||||||
| NPI: | 1578555785 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST CHAMPAIGN COUNTY FIRE DISTRICT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
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| Practice Location | |||||||||
| Address1: | 60 E MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH LEWISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430609997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377472345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 09/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | KEERAN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 9377472345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 0917299 | 05 | OH | MEDICAID | 000000155160 | 01 | OH | ANTHEM | OTHER |