1609827997 NPI number — ELLSWORTH AREA AMBULANCE SERVICE INC

Table of content: (NPI 1609827997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609827997 NPI number — ELLSWORTH AREA AMBULANCE SERVICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLSWORTH AREA 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:
Provider Other Organization Name Type Code:
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:
1609827997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 718
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLSWORTH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54011-0718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 S PLUM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54011-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-273-4879
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORTH
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
715-273-4879

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 396005590 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000082275 . This is a "ADVOCARE MCHMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8182337 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41307200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41307200 . This is a "HIRSP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 7002089 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2525186-00 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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