Provider Demographics
NPI:1720398464
Name:EXECUTIVE AIR TAXI CORP.
Entity Type:Organization
Organization Name:EXECUTIVE AIR TAXI CORP.
Other - Org Name:ANGEL AIR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CERMAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-258-5024
Mailing Address - Street 1:2301 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-7595
Mailing Address - Country:US
Mailing Address - Phone:701-258-5024
Mailing Address - Fax:701-258-2693
Practice Address - Street 1:8295 7TH AVE SE
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:ND
Practice Address - Zip Code:58552-9011
Practice Address - Country:US
Practice Address - Phone:701-254-5755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD09823416A0800X
ND6813416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54188Medicaid
SDN714975Medicare UPIN
ND54188Medicaid