Provider Demographics
NPI:1255337333
Name:BISMARCK AIR MEDICAL, LLC
Entity type:Organization
Organization Name:BISMARCK AIR MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-255-0812
Mailing Address - Street 1:PO BOX 974
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-0974
Mailing Address - Country:US
Mailing Address - Phone:701-255-0812
Mailing Address - Fax:701-255-7247
Practice Address - Street 1:2940 N 19TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5393
Practice Address - Country:US
Practice Address - Phone:701-255-0812
Practice Address - Fax:701-255-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6043416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54450Medicaid
MNA779450900Medicaid
WY124477900Medicaid
MT0441847Medicaid
NDBIS23241OtherBLUE CROSS ND
SD9020250Medicaid
WA9058983Medicaid
WA9058983Medicaid
MT0441847Medicaid