Provider Demographics
NPI:1245218742
Name:CITY OF OLIVE BRANCH
Entity Type:Organization
Organization Name:CITY OF OLIVE BRANCH
Other - Org Name:OLIVE BRANCH FIRE DEPT. AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MAYOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-892-9236
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:270-744-9600
Practice Address - Street 1:9200 PIGEON ROOST RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2421
Practice Address - Country:US
Practice Address - Phone:662-892-9236
Practice Address - Fax:662-892-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS105341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000016581OtherBLUE CROSS BLUE SHIELD
MS00050725Medicaid
TN4581042Medicaid
MS000016581OtherBLUE CROSS BLUE SHIELD