Provider Demographics
NPI:1881861300
Name:GRADY COUNTY BOARD OF COMMISSIONERS
Entity Type:Organization
Organization Name:GRADY COUNTY BOARD OF COMMISSIONERS
Other - Org Name:GRADY COUNTY EMERGENCY MEDICAL SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:DERREL
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:SR
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:229-377-6413
Mailing Address - Street 1:1700 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39827-1150
Mailing Address - Country:US
Mailing Address - Phone:229-377-6413
Mailing Address - Fax:229-377-3940
Practice Address - Street 1:1700 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39827-1150
Practice Address - Country:US
Practice Address - Phone:229-377-6413
Practice Address - Fax:229-377-3940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065-013416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85042559AAMedicare PIN