1073113759 NPI number — PHYSICIANS AMBULANCE SERVICE OF INDIANA, LLC

Table of content: (NPI 1073113759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073113759 NPI number — PHYSICIANS AMBULANCE SERVICE OF INDIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS AMBULANCE SERVICE OF INDIANA, 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:
6
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:
1073113759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 787
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT NECHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77651-0787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-619-8399
Provider Business Mailing Address Fax Number:
502-530-0103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3305 NICHOL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46011-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-619-8839
Provider Business Practice Location Address Fax Number:
502-531-0103
Provider Enumeration Date:
10/30/2020

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT MANAGING PARTNER
Authorized Official Telephone Number:
765-863-7033

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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