Provider Demographics
NPI:1700833167
Name:CITY OF DODGEVILLE
Entity Type:Organization
Organization Name:CITY OF DODGEVILLE
Other - Org Name:DODGEVILLE AREA AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EMT I
Authorized Official - Phone:608-935-5111
Mailing Address - Street 1:2715 W FRANK ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-2593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:715-834-5870
Practice Address - Street 1:100 E FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1750
Practice Address - Country:US
Practice Address - Phone:608-935-5111
Practice Address - Fax:608-935-9477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60 01312146M00000X, 146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Multi-Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41345200Medicaid
WI41345200Medicaid