Healthcare Provider Details

I. General information

NPI: 1013900364
Provider Name (Legal Business Name): MEDSTAR AMBULANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 BRADBURY LN
SPARTA IL
62286-2102
US

IV. Provider business mailing address

PO BOX 296
SPARTA IL
62286-0296
US

V. Phone/Fax

Practice location:
  • Phone: 618-443-5061
  • Fax: 618-443-3897
Mailing address:
  • Phone: 618-443-5061
  • Fax: 618-443-3897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number44837
License Number StateIL

VIII. Authorized Official

Name: DEBORAH D KELLEY
Title or Position: HUMANRESOURCES MANAGER
Credential:
Phone: 618-443-5061