Healthcare Provider Details

I. General information

NPI: 1073708129
Provider Name (Legal Business Name): STEPHENS COUNTY AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 HOSPITAL DR
TOCCOA GA
30577-6820
US

IV. Provider business mailing address

163 HOSPITAL DR
TOCCOA GA
30577-6820
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-4363
  • Fax:
Mailing address:
  • Phone: 706-282-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number12701
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000001834B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
IdentifierQAB032
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 3
Identifier1106862
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MICHAEL HESTER
Title or Position: CEO
Credential:
Phone: 706-282-4200