Provider Demographics
NPI:1780631424
Name:BERTIE AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:BERTIE AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LIPSCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-794-9141
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-0555
Mailing Address - Country:US
Mailing Address - Phone:252-794-9141
Mailing Address - Fax:252-794-9127
Practice Address - Street 1:606 S KING ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-1422
Practice Address - Country:US
Practice Address - Phone:252-794-9141
Practice Address - Fax:252-794-9127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1463341600000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0724YOtherBCBS OF NC
NC3403886Medicaid
NC3403886Medicaid