=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023770211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAMAN HEALTH EMS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2021
-----------------------------------------------------
Last Update Date | 10/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4777 E OUTER DR
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48234-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-300-5750
-----------------------------------------------------
Fax | 586-913-8018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4777 E OUTER DR
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48234-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-300-5750
-----------------------------------------------------
Fax | 586-913-8018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | MR. MICHAEL JAMES KOWALSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-652-3053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------