Provider Demographics
NPI:1265488746
Name:WILLIE GOSS AMBULANCE SERVICE
Entity Type:Organization
Organization Name:WILLIE GOSS AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-289-1523
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-0303
Mailing Address - Country:US
Mailing Address - Phone:662-289-1523
Mailing Address - Fax:662-289-1597
Practice Address - Street 1:806 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3130
Practice Address - Country:US
Practice Address - Phone:662-289-1523
Practice Address - Fax:662-289-1597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS318341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI82698300Medicaid
MS00552958Medicaid