Basic Information
Provider Information | |||||||||
NPI: | 1790907251 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITY OF NASHWAUK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NASHWAUK AMBULANCE SERVICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 E 25TH ST | ||||||||
Address2: |   | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557463897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183123002 | ||||||||
FaxNumber: | 2183123003 | ||||||||
Practice Location | |||||||||
Address1: | 301 CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | NASHWAUK | ||||||||
State: | MN | ||||||||
PostalCode: | 557691131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183123002 | ||||||||
FaxNumber: | 2183123003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 01/31/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALIGURE | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2183123002 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X |   | MN | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 590014445 | 01 | MN | RAILROAD MEDICARE | OTHER | 120025 | 01 | MN | UCARE | OTHER | 053435800 | 05 | MN |   | MEDICAID | 72503NA | 01 | MN | BLUE SHIELD | OTHER |