Provider Demographics
NPI:1437260528
Name:JACKSON COUNTY
Entity Type:Organization
Organization Name:JACKSON COUNTY
Other - Org Name:JACKSON COUNTY AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-529-5158
Mailing Address - Street 1:10169 OLD HIGHWAY 13
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-5534
Mailing Address - Country:US
Mailing Address - Phone:618-529-5158
Mailing Address - Fax:618-529-4387
Practice Address - Street 1:10169 OLD HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-5534
Practice Address - Country:US
Practice Address - Phone:618-529-5158
Practice Address - Fax:618-529-4387
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL551983416L0300X, 343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8862812OtherBLACK LUNG
IL0106019OtherBC & BS OF TN
ILP00290482OtherPALMETTO GBA
IL039780118OtherBLUE CROSS BLUE SHIELD
ILHEALTHLINKOther112726
IL8862812OtherBLACK LUNG
ILP00290482OtherPALMETTO GBA