=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194729855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEAST IOWA AMBULANCE SERVICE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4165 NAPLES AVE SW STE 5
-----------------------------------------------------
City | IOWA CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52240-8624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-466-0735
-----------------------------------------------------
Fax | 319-466-0740
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4165 NAPLES AVE SW STE 5
-----------------------------------------------------
City | IOWA CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52240-8624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-466-0735
-----------------------------------------------------
Fax | 319-466-0740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/CEO
-----------------------------------------------------
Name | MR. RUSSELL JOHN BAILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 319-466-0735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 2520400
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------