MEDICARE: CARROLL COUNTY AMBULANCE DISTRICT

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	033014	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	100472	OTHER	MO	EDI
2	03576019	OTHER	MO	BLUE CROSS BLUE SHIELD
3	10K4112	OTHER	MO	BCBS OF MO

General Provider Information

NPI Number	:	1508859331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARROLL COUNTY AMBULANCE DISTRICT

Provider Business Mailing Address
First Line	:	603 N MASON ST
Second Line	:	P.O. BOX 511
City	:	CARROLLTON
State	:	MO
Zip	:	64633-2252
Country	:	US
Telephone Number	:	660-542-1808
Fax Number	:	660-542-1072

Provider Business Practice Location Address
First Line	:	603 N MASON ST
Second Line	:
City	:	CARROLLTON
State	:	MO
Zip	:	64633-2252
Country	:	US
Telephone Number	:	660-542-1808
Fax Number	:	660-542-1072

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. SHERI CLAVIN
Credential	:	EMTP
Telephone Number	:	660-542-1808

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	08/22/2020

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Directions to “CARROLL COUNTY AMBULANCE DISTRICT ” Practice Location

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