Basic Information
Provider Information | |||||||||
NPI: | 1528075850 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HANOVER AMBULANCE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3920 13TH AVE E | ||||||||
Address2: | SUITE 6 | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557463675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182637540 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10 FOX STREET | ||||||||
Address2: |   | ||||||||
City: | HANOVER | ||||||||
State: | IL | ||||||||
PostalCode: | 61041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8155913767 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 10/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HANSON | ||||||||
AuthorizedOfficialFirstName: | MARCIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY OF EMT | ||||||||
AuthorizedOfficialTelephone: | 8155913767 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X |   |   | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 0004370616 | 01 | IL | BCBS | OTHER |