Provider Demographics
NPI:1174679906
Name:CITY OF MOUNDRIDGE
Entity Type:Organization
Organization Name:CITY OF MOUNDRIDGE
Other - Org Name:MOUNDRIDGE EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-345-3657
Mailing Address - Street 1:225 N WEDEL AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107-7540
Mailing Address - Country:US
Mailing Address - Phone:620-345-3657
Mailing Address - Fax:620-345-3665
Practice Address - Street 1:225 N WEDEL AVE
Practice Address - Street 2:
Practice Address - City:MOUNDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107-7540
Practice Address - Country:US
Practice Address - Phone:620-345-3657
Practice Address - Fax:620-345-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13503416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS005643OtherBLUE CROSS BLUE SHIELD OF KS
KS100091790AMedicaid
KS005643Medicare PIN