Provider Demographics
NPI:1487651543
Name:LYON COUNTY EMERGENCY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:LYON COUNTY EMERGENCY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-388-7167
Mailing Address - Street 1:236 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42038-8294
Mailing Address - Country:US
Mailing Address - Phone:270-388-7167
Mailing Address - Fax:270-388-7588
Practice Address - Street 1:236 COMMERCE STREET
Practice Address - Street 2:
Practice Address - City:EDDYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42038-8294
Practice Address - Country:US
Practice Address - Phone:270-388-7167
Practice Address - Fax:270-388-7588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13683416L0300X
KY3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY55072011Medicaid
KY000000221435OtherANTHEM BLUE CROSS
590013090OtherRR MEDICARE
310933801OtherFEDERAL BLACK LUNG PROGRAM
KY56004245Medicaid
KY8022201Medicare PIN
590013090OtherRR MEDICARE