Provider Demographics
NPI:1114072964
Name:CITY OF ELKHART
Entity Type:Organization
Organization Name:CITY OF ELKHART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT CHIEF OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-293-8931
Mailing Address - Street 1:PO BOX 2122
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-1122
Mailing Address - Country:US
Mailing Address - Phone:800-926-6985
Mailing Address - Fax:734-479-6319
Practice Address - Street 1:500 EAST ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3610
Practice Address - Country:US
Practice Address - Phone:574-293-8931
Practice Address - Fax:574-522-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0135341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000199574OtherBLUE CROSS
IN200269490AMedicaid
IN590014821OtherRAILROAD MEDICARE
IN179530Medicare PIN