Provider Demographics
NPI:1043417322
Name:CITY OF COSMOS
Entity Type:Organization
Organization Name:CITY OF COSMOS
Other - Org Name:COSMOS AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CITY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-877-7345
Mailing Address - Street 1:PO BOX 614
Mailing Address - Street 2:233 MILKY WAY ST. S.
Mailing Address - City:COSMOS
Mailing Address - State:MN
Mailing Address - Zip Code:56228
Mailing Address - Country:US
Mailing Address - Phone:320-877-7345
Mailing Address - Fax:320-877-7678
Practice Address - Street 1:233 MILKY WAY ST. S.
Practice Address - Street 2:
Practice Address - City:COSMOS
Practice Address - State:MN
Practice Address - Zip Code:56228
Practice Address - Country:US
Practice Address - Phone:320-877-7345
Practice Address - Fax:320-877-7678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00583416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN863367300Medicaid
599000148Medicare PIN
MN599000148Medicare ID - Type Unspecified