Basic Information
| Provider Information | |||||||||
| NPI: | 1235542333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN MEDICAL CENTER AMBULANCE SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707440834 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373342684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314387434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2014 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | BLAYLOCK | ||||||||
| AuthorizedOfficialFirstName: | DARRELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9314387455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 0000005201 | TN | N | Transportation Services | Ambulance | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 1534346 | 05 | TN | MEDICAID | P01475369 | 01 | TN | RAILROAD MEDICARE | OTHER |