Provider Demographics
NPI:1225143514
Name:CITY OF MARYSVILLE
Entity Type:Organization
Organization Name:CITY OF MARYSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:KONIK
Authorized Official - Suffix:
Authorized Official - Credentials:FIRE CHIEF
Authorized Official - Phone:810-364-6611
Mailing Address - Street 1:1355 DELAWARE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040
Mailing Address - Country:US
Mailing Address - Phone:810-364-6611
Mailing Address - Fax:810-364-6690
Practice Address - Street 1:1355 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040
Practice Address - Country:US
Practice Address - Phone:810-364-6611
Practice Address - Fax:810-364-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI741005341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI183290648Medicaid
MI0G40002Medicare PIN