Provider Demographics
NPI:1912016106
Name:COUNTY OF SOMERVELL
Entity Type:Organization
Organization Name:COUNTY OF SOMERVELL
Other - Org Name:SOMERVELL COUNTY EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNTY JUDGE
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:MARION
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-897-2322
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:111 SHEPPARD STREET
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043
Mailing Address - Country:US
Mailing Address - Phone:254-897-2135
Mailing Address - Fax:254-897-4568
Practice Address - Street 1:111 SHEPPARD STREET
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043
Practice Address - Country:US
Practice Address - Phone:254-897-2135
Practice Address - Fax:254-897-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213004146L00000X, 146M00000X, 146N00000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Multi-Specialty
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Multi-Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213004OtherTX DSHS EMS LICENSE#
TXP00280460OtherRAILROAD MEDICARE
TXAMB792OtherBLUE CROSS BLUE SHIELD OF TEXAS
TXAMB792OtherBLUE CROSS BLUE SHIELD OF TEXAS