1891782595 NPI number — MEDSHORE AMBULANCE SERVICE, LLC

Table of content: (NPI 1891782595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891782595 NPI number — MEDSHORE AMBULANCE SERVICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSHORE AMBULANCE SERVICE, 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:
1891782595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650458
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-597-4911
Provider Business Mailing Address Fax Number:
866-687-2796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 ELLA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29621-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-260-4600
Provider Business Practice Location Address Fax Number:
864-260-4575
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JEWELL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF REVENUE INTEGRATION OFFICER
Authorized Official Telephone Number:
844-597-4911

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  224 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 343900000X , with the licence number: 7241 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 502236 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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