Provider Demographics
NPI:1306899430
Name:MOUNT CALVARY AMBULANCE SERVICE INC
Entity type:Organization
Organization Name:MOUNT CALVARY AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PFEIFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-753-6086
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:MOUNT CALVARY
Mailing Address - State:WI
Mailing Address - Zip Code:53057-0088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:999 FOND DU LAC ST
Practice Address - Street 2:
Practice Address - City:MOUNT CALVARY
Practice Address - State:WI
Practice Address - Zip Code:53057-9772
Practice Address - Country:US
Practice Address - Phone:920-753-6086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
000081003OtherADVOCARE MCHMO
WI41328000OtherHIRSP
11518OtherHERITAGE NATIONAL
11518OtherNETWORK HEALTH PLAN
WI41328000Medicaid
=========011OtherVALLEY HEALTH PLAN
=========OtherBENEFIT ADMINISTRATORS
WI41328000Medicaid
=========OtherBENEFIT ADMINISTRATORS
P00124212Medicare ID - Type UnspecifiedRAILROAD MEDICARE