Provider Demographics
NPI:1336226034
Name:MECKLENBURG EMERGENCY MEDICAL SERVICES AGENCY
Entity Type:Organization
Organization Name:MECKLENBURG EMERGENCY MEDICAL SERVICES AGENCY
Other - Org Name:MEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-943-6400
Mailing Address - Street 1:PO BOX 741033
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1033
Mailing Address - Country:US
Mailing Address - Phone:704-943-6400
Mailing Address - Fax:704-943-6196
Practice Address - Street 1:4425 WILKINSON BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208
Practice Address - Country:US
Practice Address - Phone:704-943-6000
Practice Address - Fax:704-943-6196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0600621146L00000X, 341600000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Single Specialty
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406780Medicaid
NC590011342OtherRAILROAD MEDICARE
NC590011342OtherRAILROAD MEDICARE