=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467664938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULFPORT AMBULANCE SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 08/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RR 1 BOX 84
-----------------------------------------------------
City | CARMAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61425-9718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-873-2575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RR 1 BOX 84
-----------------------------------------------------
City | CARMAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61425-9718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. ED RONNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-873-2575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1770779
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------