Provider Demographics
NPI:1285693861
Name:NORTHEAST IOWA MEDICAL TRANSPORT, INC.
Entity type:Organization
Organization Name:NORTHEAST IOWA MEDICAL TRANSPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC, CRITICAL
Authorized Official - Phone:563-422-9459
Mailing Address - Street 1:704 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:IA
Mailing Address - Zip Code:52175-1018
Mailing Address - Country:US
Mailing Address - Phone:563-422-3723
Mailing Address - Fax:563-422-3723
Practice Address - Street 1:704 N VINE ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1018
Practice Address - Country:US
Practice Address - Phone:563-422-3723
Practice Address - Fax:563-422-3723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23304003416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0171249Medicaid
IA45076Medicare ID - Type Unspecified