Provider Demographics
NPI:1982693495
Name:CITY OF DE PERE
Entity Type:Organization
Organization Name:CITY OF DE PERE
Other - Org Name:CITY OF DE PERE AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-339-4085
Mailing Address - Street 1:400 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2717
Mailing Address - Country:US
Mailing Address - Phone:920-339-4085
Mailing Address - Fax:920-403-7883
Practice Address - Street 1:400 LEWIS ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2717
Practice Address - Country:US
Practice Address - Phone:920-339-4085
Practice Address - Fax:920-403-7883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF DE PERE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-18
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60010253416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41328800Medicaid
WI0000083192OtherMEDICARE PTAN
WI0000083192OtherMEDICARE PTAN