Provider Demographics
NPI:1629192422
Name:CITY OF WINNEBAGO
Entity Type:Organization
Organization Name:CITY OF WINNEBAGO
Other - Org Name:WINNEBAGO AREA AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AMBULANCE BILLING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MAURIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-893-3217
Mailing Address - Street 1:140 MAIN SOUTH
Mailing Address - Street 2:PO BOX 35
Mailing Address - City:WINNEBAGO
Mailing Address - State:MN
Mailing Address - Zip Code:56098-0035
Mailing Address - Country:US
Mailing Address - Phone:507-893-3217
Mailing Address - Fax:507-893-3473
Practice Address - Street 1:140 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:MN
Practice Address - Zip Code:56098-0035
Practice Address - Country:US
Practice Address - Phone:507-893-3217
Practice Address - Fax:507-893-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0271146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42636Medicare ID - Type Unspecified