Provider Demographics
NPI:1831244144
Name:FULTON COUNTY EMERGENCY MEDICAL ASSOCIATION, INC.
Entity type:Organization
Organization Name:FULTON COUNTY EMERGENCY MEDICAL ASSOCIATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:F
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-647-5147
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:635 S MAIN ST
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-0250
Mailing Address - Country:US
Mailing Address - Phone:309-647-5147
Mailing Address - Fax:309-647-6521
Practice Address - Street 1:635 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-3035
Practice Address - Country:US
Practice Address - Phone:309-647-5147
Practice Address - Fax:309-647-6521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2512341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid