MEDICARE: CITY OF MAPLE LAKE

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	341600000X	Ambulance	147	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	55023MA	OTHER	MN	BLUE CROSS
2	25107-469153224	OTHER	MN	MEDICA
3	602067400	OTHER	MN	MN MA

General Provider Information

NPI Number	:	1538220926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF MAPLE LAKE

Provider Business Mailing Address
First Line	:	10 MAPLE AVE S
Second Line	:	PO BOX 757
City	:	MAPLE LAKE
State	:	MN
Zip	:	55358-4558
Country	:	US
Telephone Number	:	320-963-3611
Fax Number	:	320-963-6612

Provider Business Practice Location Address
First Line	:	10 MAPLE AVE S
Second Line	:
City	:	MAPLE LAKE
State	:	MN
Zip	:	55358-4558
Country	:	US
Telephone Number	:	320-963-3611
Fax Number	:	320-963-6612

Authorized Official
Title or Position	:	CITY CLERK
Name	:	LEE ANN YAGER
Credential	:
Telephone Number	:	320-963-3611

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	12/09/2016

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Directions to “CITY OF MAPLE LAKE ” Practice Location

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