MEDICARE: SOUTHSIDE RESCUE SQUAD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	351129	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1093700742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE RESCUE SQUAD INC

Provider Business Mailing Address
First Line	:	PO BOX 660
Second Line	:
City	:	SOUTH HILL
State	:	VA
Zip	:	23970-0660
Country	:	US
Telephone Number	:	434-447-5038
Fax Number	:

Provider Business Practice Location Address
First Line	:	810 W ATLANTIC ST
Second Line	:
City	:	SOUTH HILL
State	:	VA
Zip	:	23970-1808
Country	:	US
Telephone Number	:	434-447-5038
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	MR. FLOYD EDMONDS
Credential	:
Telephone Number	:	434-447-5038

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	10/15/2007

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