=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336226034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MECKLENBURG EMERGENCY MEDICAL SERVICES AGENCY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 05/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4425 WILKINSON BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-943-6000
-----------------------------------------------------
Fax | 704-943-6196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 741033
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-943-6400
-----------------------------------------------------
Fax | 704-943-6196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JOHN PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-943-6400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146L00000X
-----------------------------------------------------
Taxonomy Name | Paramedic
-----------------------------------------------------
License Number | 0600621
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 0600621
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 0600621
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------