MEDICARE: CMS PROFESSIONAL TRANSPORT, 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	343900000X	Non-emergency Medical Transport (VAN)		FL

General Provider Information

NPI Number	:	1619262789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CMS PROFESSIONAL TRANSPORT, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2227
Second Line	:	181 SE HERNANDO AVE.
City	:	LAKE CITY
State	:	FL
Zip	:	32056-2227
Country	:	US
Telephone Number	:	386-752-2112
Fax Number	:	386-758-9047

Provider Business Practice Location Address
First Line	:	181 SE HERNANDO AVE
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-4428
Country	:	US
Telephone Number	:	386-752-2112
Fax Number	:	386-758-9047

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHRIS SAMSON
Credential	:
Telephone Number	:	386-752-2112

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	06/16/2011

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