Basic Information
| Provider Information | |||||||||
| NPI: | 1487651543 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LYON COUNTY EMERGENCY AMBULANCE SERVICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| 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: | 2707440834 | ||||||||
| Practice Location | |||||||||
| Address1: | 236 COMMERCE STREET | ||||||||
| Address2: | |||||||||
| City: | EDDYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420388294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703887167 | ||||||||
| FaxNumber: | 2703887588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PANCAKE | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 7028832214 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | KY | N | Transportation Services | Ambulance | Land Transport | 3416L0300X | 1368 | KY | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 000000221435 | 01 | KY | ANTHEM BLUE CROSS | OTHER | 56004245 | 05 | KY | MEDICAID | 310933801 | 01 | FEDERAL BLACK LUNG PROGRAM | OTHER | 55072011 | 05 | KY | MEDICAID | 590013090 | 01 | RR MEDICARE | OTHER |