Provider Demographics
NPI:1073517942
Name:MIDWEST MEDFLIGHT
Entity Type:Organization
Organization Name:MIDWEST MEDFLIGHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:734-712-3104
Mailing Address - Street 1:5305 MCAULEY DR
Mailing Address - Street 2:# 311
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1051
Mailing Address - Country:US
Mailing Address - Phone:734-712-3104
Mailing Address - Fax:816-431-4973
Practice Address - Street 1:5305 MCAULEY DR
Practice Address - Street 2:# 311
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3104
Practice Address - Fax:816-431-4973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8110073416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI59OH10002OtherBCBSMI
MI59OH10002OtherBCBSMI
MI0H10002Medicare PIN