Basic Information
| Provider Information | |||||||||
| NPI: | 1013952795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND LEDGE AREA EMERGENCY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2869 JOLLY RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179083980 | ||||||||
| FaxNumber: | 5179083981 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | GRAND LEDGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488371620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176271157 | ||||||||
| FaxNumber: | 5176270417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 02/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | HINDS | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | EMS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5176271157 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 231021 | MI | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 590B310590 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 184720743 | 05 | MI | MEDICAID | P00218393 | 01 | RAILROAD MEDICARE | OTHER | 200000003600 | 01 | MI | PHP | OTHER |