Provider Demographics
NPI:1023627395
Name:IMPACT MEDICAL TRANSPORT
Entity type:Organization
Organization Name:IMPACT MEDICAL TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARAMEDIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-617-3024
Mailing Address - Street 1:1067 MASON ST
Mailing Address - Street 2:
Mailing Address - City:BARRY
Mailing Address - State:IL
Mailing Address - Zip Code:62312-1134
Mailing Address - Country:US
Mailing Address - Phone:217-617-3024
Mailing Address - Fax:217-919-0719
Practice Address - Street 1:915 IL-106
Practice Address - Street 2:
Practice Address - City:BARRY
Practice Address - State:IL
Practice Address - Zip Code:62312
Practice Address - Country:US
Practice Address - Phone:217-617-3024
Practice Address - Fax:217-919-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)