1770528606 NPI number — FM AMBULANCE SERVICE, INC

Table of content: (NPI 1770528606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770528606 NPI number — FM AMBULANCE SERVICE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FM AMBULANCE SERVICE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SANFORD AMBULANCE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770528606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 18TH ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-5105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-234-1262
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 18TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-5105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-364-1700
Provider Business Practice Location Address Fax Number:
701-364-1705
Provider Enumeration Date:
06/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MORRISON
Authorized Official First Name:
TONY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
VICE PRESIDENT, REVENUE CYCLE
Authorized Official Telephone Number:
605-328-8380

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  035 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3416L0300X , with the licence number: 0166 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X , with the licence number: 56 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7009 . This is a "NDBC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 81-20887 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 141853000 . This is a "US DEPT LABOR WORK COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 991369600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10525 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50012 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61180FM . This is a "MNBC" identifier . This identifiers is of the category "OTHER".