Provider Demographics
NPI:1780709139
Name:MILLSTADT AMBULANCE SERVICE
Entity type:Organization
Organization Name:MILLSTADT AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGET
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-476-1201
Mailing Address - Street 1:100 E LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:MILLSTADT
Mailing Address - State:IL
Mailing Address - Zip Code:62260-1510
Mailing Address - Country:US
Mailing Address - Phone:618-476-1201
Mailing Address - Fax:
Practice Address - Street 1:100 E LAUREL ST
Practice Address - Street 2:
Practice Address - City:MILLSTADT
Practice Address - State:IL
Practice Address - Zip Code:62260-1510
Practice Address - Country:US
Practice Address - Phone:618-476-1201
Practice Address - Fax:618-476-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001MedicaidAMBULANCE PROVIDER
IL=========001Medicaid
IL=========OtherAMBULANCE PROVIDER
IL=========001Medicaid