Provider Demographics
NPI:1164644662
Name:LONGYEAR INC OF CHISHOLM
Entity Type:Organization
Organization Name:LONGYEAR INC OF CHISHOLM
Other - Org Name:CHISHOLM AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SERTICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-312-3002
Mailing Address - Street 1:1200 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3897
Mailing Address - Country:US
Mailing Address - Phone:218-312-3002
Mailing Address - Fax:218-263-8933
Practice Address - Street 1:329 1ST ST NW
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-1703
Practice Address - Country:US
Practice Address - Phone:218-312-3002
Practice Address - Fax:218-263-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69127CHOtherBLUE CROSS BLUE SHIELD
MN920767800Medicaid
MN590002778OtherRAILROAD MEDICARE
MN599000073Medicare PIN