1881683548 NPI number — PHOENIX EMERGENCY SERVICES OF MADISON LLC

Table of content: (NPI 1881683548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881683548 NPI number — PHOENIX EMERGENCY SERVICES OF MADISON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX EMERGENCY SERVICES OF MADISON LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881683548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2828 CROASDAILE DR
Provider Second Line Business Mailing Address:
PHOENIX EMERGENCY SERVICES OF MADISON
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27705-2505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-751-1157
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 KINGS DAUGHTERS DR
Provider Second Line Business Practice Location Address:
PHOENIX EMERGENCY SERVICES OF MADISON
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47250-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-265-5211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
877-751-1157

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00000380234 . This is a "BLUE CROSS BLUE SHIELD OF IN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200540070 A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2640517000 . This is a "PASSPORT HEALTHPLAN ADVANTAGE HMO MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 78904984 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65944647 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50009161 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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