Provider Demographics
NPI:1619025889
Name:CITY OF FOND DU LAC
Entity type:Organization
Organization Name:CITY OF FOND DU LAC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR ACCOUNTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-322-3454
Mailing Address - Street 1:160 S MACY ST
Mailing Address - Street 2:PO BOX 150
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4241
Mailing Address - Country:US
Mailing Address - Phone:920-322-3454
Mailing Address - Fax:920-322-3402
Practice Address - Street 1:815 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5738
Practice Address - Country:US
Practice Address - Phone:920-322-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60003443416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41323900Medicaid
WI590094069OtherMEDICARE RAILROAD
WI=========012OtherANTHEM BCBS
WI000082328Medicare ID - Type Unspecified