1700096328 NPI number — MCINTOSH VOLUNTEER FIRE DEPARTMENT AMBULANCE SERVICE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700096328 NPI number — MCINTOSH VOLUNTEER FIRE DEPARTMENT AMBULANCE SERVICE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCINTOSH VOLUNTEER FIRE DEPARTMENT 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:
1700096328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 174
Provider Second Line Business Mailing Address:
120 1ST AVE. EAST
Provider Business Mailing Address City Name:
MC INTOSH
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57641-0174
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:
120 1ST AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MC INTOSH
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57641-0174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-273-4210
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BUBBERS
Authorized Official First Name:
SUE OR GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CAPTAIN
Authorized Official Telephone Number:
605-273-4469

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  80 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X , with the licence number: 0201 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9001170 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0099232 . This is a "WELLMARK" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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