Basic Information
| Provider Information | |||||||||
| NPI: | 1285637058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF EXCELSIOR SPRINGS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EXCELSIOR SPRINGS FIRE DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 TRACY AVE. | ||||||||
| Address2: | |||||||||
| City: | EXCELSIOR SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640241141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166303000 | ||||||||
| FaxNumber: | 8166309530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ST JOHN | ||||||||
| AuthorizedOfficialFirstName: | ZACHARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASST. CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8166303000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 047074 | MO | N | Transportation Services | Ambulance | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 800548307 | 05 | MO | MEDICAID | 200266320A | 05 | KS | MEDICAID |