Provider Demographics
NPI:1629025713
Name:CITY OF SOUTH BEND
Entity Type:Organization
Organization Name:CITY OF SOUTH BEND
Other - Org Name:SOUTH BEND FIRE DEPT. EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SKWARCAN
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-P
Authorized Official - Phone:574-235-9257
Mailing Address - Street 1:1222 S MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-3430
Mailing Address - Country:US
Mailing Address - Phone:574-235-9250
Mailing Address - Fax:574-235-9071
Practice Address - Street 1:1222 S MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-3430
Practice Address - Country:US
Practice Address - Phone:574-235-9250
Practice Address - Fax:574-235-9071
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF SOUTH BEND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01393416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000185333OtherANTHEM BCBS
IN100286930AMedicaid
MI2693941Medicaid
IN100286930AMedicaid