MEDICARE: POWELL COUNTY AMBULANCE SERVICE 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	3416L0300X	Land Ambulance	043	MT

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	00124-2	OTHER	MT	BC/BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700825478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWELL COUNTY AMBULANCE SERVICE INC

Provider Business Mailing Address
First Line	:	PO BOX 1359
Second Line	:	1243 BURLINGTON AVE
City	:	MISSOULA
State	:	MT
Zip	:	59806-1359
Country	:	US
Telephone Number	:	406-549-7104
Fax Number	:	406-542-2785

Provider Business Practice Location Address
First Line	:	1101 TEXAS AVE
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722
Country	:	US
Telephone Number	:	406-846-2212
Fax Number	:	406-846-6039

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	JOHN R UNGARETTI
Credential	:	CCEMTP
Telephone Number	:	406-549-7104

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	05/24/2013

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Directions to “POWELL COUNTY AMBULANCE SERVICE INC ” Practice Location

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