Basic Information
| Provider Information | |||||||||
| NPI: | 1194828095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GORDON-WASCOTT EMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14511 S HWY 53 | ||||||||
| Address2: | |||||||||
| City: | GORDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 538384800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153762640 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 14511 S HIGHWAY 53 | ||||||||
| Address2: | |||||||||
| City: | GORDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548384800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153762640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | EBERT | ||||||||
| AuthorizedOfficialFirstName: | BETTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7153762640 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 41326900 | 05 | WI | MEDICAID |