Basic Information
| Provider Information | |||||||||
| NPI: | 1275759748 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPALDING AMBULANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741278 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702282721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | GRIFFIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302244213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702282721 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | BURTNETT | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | KYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP OF OUTPATIENT SERVICES, TENET | ||||||||
| AuthorizedOfficialTelephone: | 4698932153 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 00000866B | 05 | GA | MEDICAID |