1306896576 NPI number — FOUNTAIN AMBULANCE SERVICE INC

Table of content: (NPI 1306896576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306896576 NPI number — FOUNTAIN AMBULANCE SERVICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAIN AMBULANCE SERVICE INC
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:
1306896576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 198408
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-8408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5237 HALLS MILL RD
Provider Second Line Business Practice Location Address:
BUILDING D
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36619-9603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-478-7200
Provider Business Practice Location Address Fax Number:
251-478-3888
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNING
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
303-495-1220

Provider Taxonomy Codes

  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AL0000D100169 . This is a "SECTION 1011" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 20049104 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 590011529 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 50165FOU . This is a "BLUECROSS BLUESHIELD OF A" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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