Provider Demographics
NPI:1992791271
Name:NORTH WAYNE COUNTY AMBULANCE SERVICE
Entity type:Organization
Organization Name:NORTH WAYNE COUNTY AMBULANCE SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:E
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-673-2046
Mailing Address - Street 1:PO BOX 133
Mailing Address - Street 2:501 PARK STREET
Mailing Address - City:CISNE
Mailing Address - State:IL
Mailing Address - Zip Code:62823-0133
Mailing Address - Country:US
Mailing Address - Phone:618-673-3011
Mailing Address - Fax:
Practice Address - Street 1:501 PARK STREET
Practice Address - Street 2:
Practice Address - City:CISNE
Practice Address - State:IL
Practice Address - Zip Code:62823-0133
Practice Address - Country:US
Practice Address - Phone:618-673-3011
Practice Address - Fax:618-673-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5014-01341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid