Basic Information
| Provider Information | |||||||||
| NPI: | 1558446419 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SHEPHERD MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHAMPION EMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033152000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 E MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033152000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BANOS | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9033152000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SHEPHERD MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | TX | N | Transportation Services | Ambulance | Land Transport | 343800000X | TX | N | Transportation Services | Secured Medical Transport (VAN) | 343900000X | TX | N | Transportation Services | Non-emergency Medical Transport (VAN) | 341600000X | TX | Y | Transportation Services | Ambulance |
No ID Information.