Provider Demographics
NPI:1225164064
Name:IRA BURROUGHS
Entity Type:Organization
Organization Name:IRA BURROUGHS
Other - Org Name:LAUGHLIN AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURROUGHS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-667-7495
Mailing Address - Street 1:205 EDWARDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-1301
Mailing Address - Country:US
Mailing Address - Phone:618-667-7495
Mailing Address - Fax:618-667-8114
Practice Address - Street 1:205 EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1301
Practice Address - Country:US
Practice Address - Phone:618-667-7495
Practice Address - Fax:618-667-8114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL448763416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370948173001Medicaid
IL370948173001Medicaid