MEDICARE: GMT TRANSPORTATION PHOENIX, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1134463334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GMT TRANSPORTATION PHOENIX, LLC

Provider Business Mailing Address
First Line	:	4147 S 37TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-1842
Country	:	US
Telephone Number	:	480-948-4655
Fax Number	:	623-258-4311

Provider Business Practice Location Address
First Line	:	4147 S 37TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-1842
Country	:	US
Telephone Number	:	480-948-4655
Fax Number	:	623-258-4311

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RIAAN KOCK
Credential	:
Telephone Number	:	480-948-4655

Provider Enumeration Date	:	11/12/2012
Last Update Date	:	11/12/2012

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