Provider Demographics
NPI:1700096328
Name:MCINTOSH VOLUNTEER FIRE DEPARTMENT AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:MCINTOSH VOLUNTEER FIRE DEPARTMENT AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAPTAIN
Authorized Official - Prefix:
Authorized Official - First Name:SUE OR GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUBBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-273-4469
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:120 1ST AVE. EAST
Mailing Address - City:MC INTOSH
Mailing Address - State:SD
Mailing Address - Zip Code:57641-0174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 1ST AVE E
Practice Address - Street 2:
Practice Address - City:MC INTOSH
Practice Address - State:SD
Practice Address - Zip Code:57641-0174
Practice Address - Country:US
Practice Address - Phone:605-273-4210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD02013416L0300X
ND803416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9001170Medicaid
SD0099232OtherWELLMARK