Provider Demographics
NPI:1083044762
Name:INTEGRATED FIRST RESPONSE-GREAT LAKES
Entity type:Organization
Organization Name:INTEGRATED FIRST RESPONSE-GREAT LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-366-3299
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20172-1137
Mailing Address - Country:US
Mailing Address - Phone:855-437-9114
Mailing Address - Fax:866-388-5227
Practice Address - Street 1:719 RIVER AVENUE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801
Practice Address - Country:US
Practice Address - Phone:855-437-9111
Practice Address - Fax:605-582-8983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2210103416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6850OtherMEDICARE PTAN