Provider Demographics
NPI:1598833915
Name:ROSEVILLE AREA AMBULANCE SVC
Entity type:Organization
Organization Name:ROSEVILLE AREA AMBULANCE SVC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:ADKISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-337-3844
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61473-0551
Mailing Address - Country:US
Mailing Address - Phone:309-426-1804
Mailing Address - Fax:
Practice Address - Street 1:571 STATE HIGHWAY 116
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:IL
Practice Address - Zip Code:61473-9666
Practice Address - Country:US
Practice Address - Phone:309-426-1804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL02 25083416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL575500Medicare PIN