Provider Demographics
NPI:1467668947
Name:SOUTHERN GREEN LAKE COUNTY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:SOUTHERN GREEN LAKE COUNTY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY-TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-398-2636
Mailing Address - Street 1:877 N. MARGARET STREET
Mailing Address - Street 2:
Mailing Address - City:MARKESAN
Mailing Address - State:WI
Mailing Address - Zip Code:53946-0075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:877 N. MARGARET STREET
Practice Address - Street 2:
Practice Address - City:MARKESAN
Practice Address - State:WI
Practice Address - Zip Code:53946-0075
Practice Address - Country:US
Practice Address - Phone:920-398-2636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60-007513416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI722414Medicaid
WI000082276Medicare Oscar/Certification
WI000082276Medicare UPIN
WI000082276Medicare PIN