MEDICARE: MEDIVAC AIR RESCUE, 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	3416A0800X	Air Ambulance		TX

General Provider Information

NPI Number	:	1477846889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDIVAC AIR RESCUE, INC.

Provider Business Mailing Address
First Line	:	5751 KROGER DR
Second Line	:	SUITE 230
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5632
Country	:	US
Telephone Number	:	877-260-3575
Fax Number	:	877-514-2571

Provider Business Practice Location Address
First Line	:	5751 KROGER DR
Second Line	:	SUITE 230
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5632
Country	:	US
Telephone Number	:	877-260-3575
Fax Number	:	877-514-2571

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. MICHAEL A NELSON
Credential	:	NREMT-P
Telephone Number	:	877-260-3575

Provider Enumeration Date	:	05/17/2011
Last Update Date	:	05/17/2011

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