Provider Demographics
NPI:1922143239
Name:BENTON COUNTY GOVERNMENT
Entity Type:Organization
Organization Name:BENTON COUNTY GOVERNMENT
Other - Org Name:BENTON COUNTY EMERGENCY AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:INDIANA CERTIFIED PA
Authorized Official - Phone:765-884-2002
Mailing Address - Street 1:604 E 2ND ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FOWLER
Mailing Address - State:IN
Mailing Address - Zip Code:47944
Mailing Address - Country:US
Mailing Address - Phone:765-884-2002
Mailing Address - Fax:765-884-2063
Practice Address - Street 1:604 E 2ND ST
Practice Address - Street 2:SUITE C
Practice Address - City:FOWLER
Practice Address - State:IN
Practice Address - Zip Code:47944
Practice Address - Country:US
Practice Address - Phone:765-884-2002
Practice Address - Fax:765-884-2063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN341600000X
341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100282190AMedicaid
IN979750Medicare ID - Type Unspecified