Provider Demographics
NPI:1548578891
Name:CITY OF KONAWA
Entity Type:Organization
Organization Name:CITY OF KONAWA
Other - Org Name:KONAWA EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMS DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:EMT INTERMEDIATE
Authorized Official - Phone:580-925-2345
Mailing Address - Street 1:122 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-2232
Mailing Address - Country:US
Mailing Address - Phone:580-925-2345
Mailing Address - Fax:580-925-3131
Practice Address - Street 1:122 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-2232
Practice Address - Country:US
Practice Address - Phone:580-925-2345
Practice Address - Fax:580-925-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS 0113416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100818800AMedicaid