Provider Demographics
NPI:1922117233
Name:JEFFERSON TWP ELKHART CO
Entity Type:Organization
Organization Name:JEFFERSON TWP ELKHART CO
Other - Org Name:JEFFERSON TOWNSHIP AMBULANCE SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-533-0261
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-0727
Mailing Address - Country:US
Mailing Address - Phone:574-293-3030
Mailing Address - Fax:574-294-1345
Practice Address - Street 1:58518 STATE ROAD 15
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-8673
Practice Address - Country:US
Practice Address - Phone:574-533-0261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01813416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
590000434OtherRRMC PTAN
IN200364730AMedicaid
IN000000211128OtherANTHEM
IN200364730AMedicaid