=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053352856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LANSING MERCY AMBULANCE SERVICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 12/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1422 E MICHIGAN AVE
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48912-2107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-482-1983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1422 E MICHIGAN AVE
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48912-2107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-482-1983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.F.O.
-----------------------------------------------------
Name | DENNIS G PALMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-482-1983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 331004
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------