MEDICARE: LIFE EMERGENCY MEDICAL SERVICE, INC.

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	3416L0300X	Land Ambulance	EMS075	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00161773	OTHER	OK	RAILROAD MEDICARE #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	730760393-001	OTHER	OK	BCBS PROVIDER #

General Provider Information

NPI Number	:	1467455691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE EMERGENCY MEDICAL SERVICE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 365
Second Line	:
City	:	ENID
State	:	OK
Zip	:	73702-0365
Country	:	US
Telephone Number	:	580-233-2245
Fax Number	:	580-242-0348

Provider Business Practice Location Address
First Line	:	302 W MAPLE AVE
Second Line	:
City	:	ENID
State	:	OK
Zip	:	73701-3808
Country	:	US
Telephone Number	:	580-233-2245
Fax Number	:	580-242-0348

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MR. JAMES S JOHNSON
Credential	:
Telephone Number	:	580-233-2245

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	10/16/2007

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