MEDICARE: PUCKETT EMERGENCY MEDICAL SERVICES, LLC

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	10123	TN
2	3416L0300X	Land Ambulance	10123	TN

General Provider Information

NPI Number	:	1720300379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUCKETT EMERGENCY MEDICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 650523
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75265-0523
Country	:	US
Telephone Number	:	844-597-4911
Fax Number	:	866-687-2796

Provider Business Practice Location Address
First Line	:	5603 RINGGOLD RD
Second Line	:
City	:	EAST RIDGE
State	:	TN
Zip	:	37412-3131
Country	:	US
Telephone Number	:	423-894-1800
Fax Number	:	770-943-5150

Authorized Official
Title or Position	:	CHIEF REVENUE INTEGRATION OFFICER
Name	:	MR. ROBERT A JEWELL
Credential	:
Telephone Number	:	844-597-4911

Provider Enumeration Date	:	02/24/2010
Last Update Date	:	08/09/2023

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