Basic Information
| Provider Information | |||||||||
| NPI: | 1508865346 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF CAMPBELLSVILLE KY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAMPBELLSVILLE TAYLOR COUNTY EMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 SOUTH COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427181337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704656717 | ||||||||
| FaxNumber: | 2707893135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MAYOR | ||||||||
| AuthorizedOfficialTelephone: | 2704653504 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 1864176 | 05 | TN | MEDICAID | 086909900 | 01 | KY | BLACK LUNG | OTHER | 56027774 | 05 | KY | MEDICAID | 2445149000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 200201650A | 05 | IN | MEDICAID | 55001101 | 05 | KY | MEDICAID | P00248582 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000340594 | 01 | KY | ANTHEM | OTHER | 2645221 | 05 | OH | MEDICAID | 1063010 | 01 | KY | PASSPORT | OTHER |