Provider Demographics
NPI:1336245463
Name:MEMPHIS MEDICAL CENTER AIR AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:MEMPHIS MEDICAL CENTER AIR AMBULANCE SERVICE, INC.
Other - Org Name:HOSPITAL WING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUTORA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:901-522-5321
Mailing Address - Street 1:P.O. BOX 205149
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-5149
Mailing Address - Country:US
Mailing Address - Phone:901-522-5321
Mailing Address - Fax:
Practice Address - Street 1:1080 EASTMORELAND AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3327
Practice Address - Country:US
Practice Address - Phone:901-522-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNEMS00000099063416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3574476Medicaid
TN4043897OtherBC/BS
KY5500075600Medicaid
TX160813501Medicaid
TN4043897OtherTENNCARE SELECT
AR148123715Medicaid
MO805962206Medicaid
MS00553958Medicaid
TN132775OtherTENNCARE BETTER HEALTH
TN22924OtherTLC
TN55982OtherTENNCARE OMNICARE/DORAL
TN3574476Medicaid
TN55982OtherTENNCARE OMNICARE/DORAL