Provider Demographics
NPI:1588141345
Name:SUPERIOR AIR-GROUND AMBULANCE SERVICES OF WISCONSIN, INC
Entity type:Organization
Organization Name:SUPERIOR AIR-GROUND AMBULANCE SERVICES OF WISCONSIN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:PATE
Authorized Official - Last Name:GODDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-903-2401
Mailing Address - Street 1:395 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1508
Mailing Address - Country:US
Mailing Address - Phone:630-538-1887
Mailing Address - Fax:630-903-2835
Practice Address - Street 1:211 MADISON ST
Practice Address - Street 2:
Practice Address - City:WALWORTH
Practice Address - State:WI
Practice Address - Zip Code:53184-9680
Practice Address - Country:US
Practice Address - Phone:630-234-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance