Basic Information
| Provider Information | |||||||||
| NPI: | 1356448740 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BATES COUNTY MEMORIAL HOSPITAL AMBULANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19793 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602007000 | ||||||||
| FaxNumber: | 6602007015 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 W NURSERY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647301840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602007000 | ||||||||
| FaxNumber: | 6602007015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUSTLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PHILLIP | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6602007000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 013005 | MO | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 800673618 | 05 | MO | MEDICAID | 013005 | 01 | MO | STATE OF MISSOURI | OTHER |