Healthcare Provider Details

I. General information

NPI: 1881990745
Provider Name (Legal Business Name): EXECUTIVE AIR TAXI CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 UNIVERSITY DR
BISMARCK ND
58504-7595
US

IV. Provider business mailing address

2301 UNIVERSITY DR
BISMARCK ND
58504-7595
US

V. Phone/Fax

Practice location:
  • Phone: 701-321-1456
  • Fax: 701-258-2693
Mailing address:
  • Phone: 701-258-5024
  • Fax: 701-258-2693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number0982
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number681
License Number StateND

VIII. Authorized Official

Name: CALLEN CERMAK
Title or Position: CFO
Credential:
Phone: 701-258-5024