Provider Demographics
NPI:1932139201
Name:BEAVER ISLAND EMS
Entity Type:Organization
Organization Name:BEAVER ISLAND EMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEDLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-448-2578
Mailing Address - Street 1:PO BOX 2122
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-1122
Mailing Address - Country:US
Mailing Address - Phone:734-479-6300
Mailing Address - Fax:734-479-6319
Practice Address - Street 1:37865 KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:BEAVER ISLAND
Practice Address - State:MI
Practice Address - Zip Code:49782
Practice Address - Country:US
Practice Address - Phone:231-448-2578
Practice Address - Fax:231-448-2578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI341600000X
MI1510053416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI181928533Medicaid
MI590A500050OtherBLUE CROSS/BLUE SHIELD MI
MI0A50005Medicare PIN