Provider Demographics
NPI:1124079389
Name:EMERGENCY MEDICAL SERVICE OF RANDOLPH COUNTY GA
Entity type:Organization
Organization Name:EMERGENCY MEDICAL SERVICE OF RANDOLPH COUNTY GA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:229-732-6632
Mailing Address - Street 1:361 RANDOLPH STREET
Mailing Address - Street 2:
Mailing Address - City:CUTHBERT
Mailing Address - State:GA
Mailing Address - Zip Code:39840-1338
Mailing Address - Country:US
Mailing Address - Phone:229-732-6632
Mailing Address - Fax:229-732-2139
Practice Address - Street 1:34 TAYLOR STREET
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840-1338
Practice Address - Country:US
Practice Address - Phone:229-732-6632
Practice Address - Fax:229-732-2139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA120013416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000002593AMedicaid
GA000002593AMedicaid