=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578504882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OGEMAW COUNTY EMERGENCY MEDICAL SERVICES AUTHORITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 09/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2872 HANSEN RD
-----------------------------------------------------
City | WEST BRANCH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48661-9317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-345-4503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 399
-----------------------------------------------------
City | WEST BRANCH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48661-0399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-345-4503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JUSTIN ROGERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 989-387-1961
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 651001
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------