Basic Information
| Provider Information | |||||||||
| NPI: | 1700890134 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAKOPEE MDEWAKANTON EMERGENCY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 FLANDREAU TRAIL | ||||||||
| Address2: | |||||||||
| City: | PRIOR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522331077 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | CROOKS | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9524458900 | ||||||||
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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 | 77M49SH | 01 | MN | BCBS | OTHER |