Basic Information
| Provider Information | |||||||||
| NPI: | 1992723944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF BIWABIK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BIWABIK FIRE DEPARTMENT AMBULANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 103 3RD AVENUE NORTH | ||||||||
| Address2: | |||||||||
| City: | BIWABIK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557080529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188654183 | ||||||||
| FaxNumber: | 2188654580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | JACOBSON | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CITY ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2188654183 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 0027 | MN | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 382768200 | 05 | MN | MEDICAID | 70215CI | 01 | MN | BCBS | OTHER |