Provider Demographics
NPI:1649228123
Name:BEACON AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:BEACON AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-561-3200
Mailing Address - Street 1:300 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54534-1523
Mailing Address - Country:US
Mailing Address - Phone:715-561-3200
Mailing Address - Fax:
Practice Address - Street 1:101 E CLOVERLAND DR
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1227
Practice Address - Country:US
Practice Address - Phone:906-932-3434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI991001341600000X
WI6000577341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI590B70005OtherBLUE CROSS BLUE SHIELD
MI9512565Medicaid
WI41335300Medicaid
MI0B70005Medicare ID - Type Unspecified
MI590B70005OtherBLUE CROSS BLUE SHIELD