Provider Demographics
NPI:1396828133
Name:CITY OF GRACEVILLE
Entity Type:Organization
Organization Name:CITY OF GRACEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CITY OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-748-7911
Mailing Address - Street 1:415 STUDDART AVE
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56240-5002
Mailing Address - Country:US
Mailing Address - Phone:320-748-7911
Mailing Address - Fax:320-748-7338
Practice Address - Street 1:415 STUDDART AVENUE
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:MN
Practice Address - Zip Code:56240-0231
Practice Address - Country:US
Practice Address - Phone:320-748-7911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN030722022OtherPRIME WEST
MN49110GROtherBCBSMN
MN534868400Medicaid
MN590000074Medicare ID - Type UnspecifiedWISCONSIN PHYSICIAN'S SER