Basic Information
| Provider Information | |||||||||
| NPI: | 1164644662 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONGYEAR INC OF CHISHOLM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHISHOLM AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 E 25TH ST | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183123002 | ||||||||
| FaxNumber: | 2182638933 | ||||||||
| Practice Location | |||||||||
| Address1: | 329 1ST ST NW | ||||||||
| Address2: | |||||||||
| City: | CHISHOLM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557191703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183123002 | ||||||||
| FaxNumber: | 2182638833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | SERTICH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2183123002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | MN | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 69127CH | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 920767800 | 05 | MN | MEDICAID | 590002778 | 01 | MN | RAILROAD MEDICARE | OTHER |