Basic Information
| Provider Information | |||||||||
| NPI: | 1003853375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF NOBLESVILLE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NOBLESVILLE FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 502250 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462507250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177756753 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 S 9TH ST | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460602620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177701419 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MACKY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EMS CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 3177756753 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 200262450 | 05 | IN | MEDICAID |