Provider Demographics
NPI:1376684738
Name:EASTERN MARSHALL COUNTY EMS
Entity Type:Organization
Organization Name:EASTERN MARSHALL COUNTY EMS
Other - Org Name:EASTERN MARSHALL COUNTY EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:STIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-853-0044
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:210 NORTH CHESTNUT ST
Mailing Address - City:WENONA
Mailing Address - State:IL
Mailing Address - Zip Code:61377-0708
Mailing Address - Country:US
Mailing Address - Phone:815-853-0044
Mailing Address - Fax:815-853-0044
Practice Address - Street 1:210 NORTH CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WENONA
Practice Address - State:IL
Practice Address - Zip Code:61377-0708
Practice Address - Country:US
Practice Address - Phone:815-853-0044
Practice Address - Fax:815-853-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22565341600000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590015425OtherPALMETTO GBA
IL=========001Medicaid
IL265500Medicare PIN