Provider Demographics
NPI:1689787715
Name:GREAT DIVIDE AMBULANCE SERVICE
Entity Type:Organization
Organization Name:GREAT DIVIDE AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SERVICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-798-3094
Mailing Address - Street 1:43555 US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:CABLE
Mailing Address - State:WI
Mailing Address - Zip Code:54821-2000
Mailing Address - Country:US
Mailing Address - Phone:715-798-3094
Mailing Address - Fax:715-798-4442
Practice Address - Street 1:43555 US HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:CABLE
Practice Address - State:WI
Practice Address - Zip Code:54821-2000
Practice Address - Country:US
Practice Address - Phone:715-798-3094
Practice Address - Fax:715-798-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391913499019OtherBCBS
WI41355200Medicaid
WI41355200Medicaid
WIP00071403Medicare PIN