MEDICARE: CITY OF CUBA CITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1026785	OTHER	PHYSICIAN'S PLUS
2	000082231	OTHER	ADVOCARE MCHMO
3	WI0101	OTHER	JOHN DEERE
4	099305	OTHER	HEALTH ALLIANCE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407801905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF CUBA CITY

Provider Business Mailing Address
First Line	:	1031 S MAIN ST
Second Line	:
City	:	CUBA CITY
State	:	WI
Zip	:	53807-1599
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1013 SOUTH MAIN
Second Line	:
City	:	CUBA CITY
State	:	WI
Zip	:	53807
Country	:	US
Telephone Number	:	608-744-8753
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARIE WIEDERHOLT
Credential	:
Telephone Number	:	608-744-8753

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	11/17/2014

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Directions to “CITY OF CUBA CITY ” Practice Location

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