Provider Demographics
NPI:1891782595
Name:MEDSHORE AMBULANCE SERVICE, LLC
Entity Type:Organization
Organization Name:MEDSHORE AMBULANCE SERVICE, LLC
Other - Org Name:MEDSHORE AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF REVENUE INTEGRATION OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-597-4911
Mailing Address - Street 1:PO BOX 650458
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0458
Mailing Address - Country:US
Mailing Address - Phone:844-597-4911
Mailing Address - Fax:866-687-2796
Practice Address - Street 1:1011 ELLA ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4807
Practice Address - Country:US
Practice Address - Phone:864-260-4600
Practice Address - Fax:864-260-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC224341600000X
SC7241343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC502236Medicaid
SC502236Medicaid