Provider Demographics
NPI:1952683229
Name:SUPERIOR AIR-GROUND AMBULANCE SERVICE OF INDIANA, INC
Entity Type:Organization
Organization Name:SUPERIOR AIR-GROUND AMBULANCE SERVICE OF INDIANA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:PATE
Authorized Official - Last Name:GODDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-832-2000
Mailing Address - Street 1:395 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1508
Mailing Address - Country:US
Mailing Address - Phone:630-832-2012
Mailing Address - Fax:630-832-2169
Practice Address - Street 1:2605 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1609
Practice Address - Country:US
Practice Address - Phone:830-832-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06503416A0800X, 3416L0300X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No3416A0800XTransportation ServicesAmbulanceAir Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2012654050AMedicaid
IN2012654050AMedicaid