Provider Demographics
NPI:1194777359
Name:CITY OF OCONOMOWOC
Entity type:Organization
Organization Name:CITY OF OCONOMOWOC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEIDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-569-3223
Mailing Address - Street 1:212 S CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3503
Mailing Address - Country:US
Mailing Address - Phone:262-569-3223
Mailing Address - Fax:262-569-3297
Practice Address - Street 1:212 S CONCORD RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3503
Practice Address - Country:US
Practice Address - Phone:262-569-3223
Practice Address - Fax:262-569-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001152341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41306800Medicaid
WI791590219OtherRR CARE
WI=========OtherTRICARE
WI=========018OtherBCBS
WI000085734Medicare ID - Type Unspecified