Healthcare Provider Details

I. General information

NPI: 1023627395
Provider Name (Legal Business Name): IMPACT MEDICAL TRANSPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 IL-106
BARRY IL
62312
US

IV. Provider business mailing address

1067 MASON ST
BARRY IL
62312-1134
US

V. Phone/Fax

Practice location:
  • Phone: 217-617-3024
  • Fax: 217-919-0719
Mailing address:
  • Phone: 217-617-3024
  • Fax: 217-919-0719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: JAY ALBERT
Title or Position: PARAMEDIC/OWNER
Credential:
Phone: 217-617-3024