Provider Demographics
NPI:1063542330
Name:PUTNAM COUNTY AMBULANCE DISTRICT
Entity type:Organization
Organization Name:PUTNAM COUNTY AMBULANCE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL, ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUSHNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-947-3649
Mailing Address - Street 1:2206 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63565-1061
Mailing Address - Country:US
Mailing Address - Phone:660-947-3670
Mailing Address - Fax:660-947-3710
Practice Address - Street 1:2206 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:63565-1061
Practice Address - Country:US
Practice Address - Phone:660-947-3670
Practice Address - Fax:660-947-3710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1710183416L0300X, 341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO800548802Medicaid
MOMA2945OtherMEDICARE
MO800548802Medicaid