Provider Demographics
NPI:1124296926
Name:CAZENOVIA FD RESCUE SQUAD
Entity type:Organization
Organization Name:CAZENOVIA FD RESCUE SQUAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER-SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-983-2840
Mailing Address - Street 1:401 STATE HWY 58 NORTH
Mailing Address - Street 2:PO BOX 183
Mailing Address - City:CAZENOVIA
Mailing Address - State:WI
Mailing Address - Zip Code:53924-0183
Mailing Address - Country:US
Mailing Address - Phone:608-983-2840
Mailing Address - Fax:608-983-2215
Practice Address - Street 1:401 STATE HWY 58 NORTH
Practice Address - Street 2:310 HWY 58 NORTH
Practice Address - City:CAZENOVIA
Practice Address - State:WI
Practice Address - Zip Code:53924-0183
Practice Address - Country:US
Practice Address - Phone:608-983-2840
Practice Address - Fax:608-983-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
146N00000X
WI60-00515302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41341700Medicaid
WI41341700Medicaid