MEDICARE: GENOA-KINGSTON FIRE PROTECTION DISTRICT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance	1101602	IL
2	341600000X	Ambulance	1101601	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001915180	OTHER	IL	BLUE CROSS PROVIDER #
2	590028238	OTHER	IL	RR/MC PROVIDER #

General Provider Information

NPI Number	:	1861422081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENOA-KINGSTON FIRE PROTECTION DISTRICT

Provider Business Mailing Address
First Line	:	317 E RAILROAD AVE
Second Line	:
City	:	GENOA
State	:	IL
Zip	:	60135-1247
Country	:	US
Telephone Number	:	815-784-3412
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 E RAILROAD AVE
Second Line	:
City	:	GENOA
State	:	IL
Zip	:	60135-1247
Country	:	US
Telephone Number	:	815-784-2300
Fax Number	:

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	MR. BRUCE KOZLOWSKI
Credential	:
Telephone Number	:	815-784-3412

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	09/12/2012

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Directions to “GENOA-KINGSTON FIRE PROTECTION DISTRICT ” Practice Location

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