Provider Demographics
NPI:1326121104
Name:SPIRIT MEDICAL TRANSPORT, LLC
Entity Type:Organization
Organization Name:SPIRIT MEDICAL TRANSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-548-2800
Mailing Address - Street 1:5484 OHIO ROUTE 49 SOUTH
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1031
Mailing Address - Country:US
Mailing Address - Phone:937-548-2800
Mailing Address - Fax:937-548-2826
Practice Address - Street 1:5484 OHIO ROUTE 49 SOUTH
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1031
Practice Address - Country:US
Practice Address - Phone:937-548-2800
Practice Address - Fax:937-548-2826
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPIRIT MEDICAL TRANSPORT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
OH190062341600000X
OH195055343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2737757Medicaid
OH2740421Medicaid
OH9367181Medicare PIN