Provider Demographics
NPI:1720046188
Name:SUPERIOR AIR-GROUND AMBULANCE SERVICE OF MICHIGAN, INC
Entity Type:Organization
Organization Name:SUPERIOR AIR-GROUND AMBULANCE SERVICE OF MICHIGAN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:PATE
Authorized Official - Last Name:GODDEN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:630-903-2401
Mailing Address - Street 1:395 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1508
Mailing Address - Country:US
Mailing Address - Phone:630-538-1887
Mailing Address - Fax:630-903-2835
Practice Address - Street 1:2000 CENTERWOOD DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091
Practice Address - Country:US
Practice Address - Phone:313-832-8558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5010403416A0800X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI058738OtherHAP(HEALTH ALLIANCE PLAN)
MI0E01788OtherBLUECROSS BLUESHIELD
MI188077058Medicaid
MIP00381837OtherRAILROAD MEDICARE
MI0P21600Medicare ID - Type Unspecified