Provider Demographics
NPI:1609827997
Name:ELLSWORTH AREA AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:ELLSWORTH AREA AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-273-4879
Mailing Address - Street 1:PO BOX 718
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-0718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 S PLUM ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011-4137
Practice Address - Country:US
Practice Address - Phone:715-273-4879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
396005590OtherTRICARE
000082275OtherADVOCARE MCHMO
8182337OtherMEDICA
WI41307200Medicaid
WI41307200OtherHIRSP
7002089OtherPREFERRED ONE
MN2525186-00Medicaid
MN2525186-00Medicaid
7002089OtherPREFERRED ONE
8182337OtherMEDICA
=========012OtherMEDICARE BLUE MCHMO
000082275OtherADVOCARE MCHMO