Provider Demographics
NPI:1235542333
Name:LINCOLN MEDICAL CENTER AMBULANCE SERVICE
Entity Type:Organization
Organization Name:LINCOLN MEDICAL CENTER AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-438-7455
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:106 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2684
Practice Address - Country:US
Practice Address - Phone:931-438-7434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000005201341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1534346Medicaid
TNP01475369OtherRAILROAD MEDICARE