Provider Demographics
NPI:1013025642
Name:BULLOCH COUNTY EMERGENCY MEDICAL SERVICE
Entity Type:Organization
Organization Name:BULLOCH COUNTY EMERGENCY MEDICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-764-6188
Mailing Address - Street 1:PO BOX 1409
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1409
Mailing Address - Country:US
Mailing Address - Phone:912-764-6188
Mailing Address - Fax:912-489-8917
Practice Address - Street 1:26 W GRADY ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2742
Practice Address - Country:US
Practice Address - Phone:912-764-6188
Practice Address - Fax:912-489-8917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016023416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00263227AMedicaid
GA85049759AAMedicare PIN