Provider Demographics
NPI:1154435238
Name:GALLUP MED FLIGHT, LLC
Entity type:Organization
Organization Name:GALLUP MED FLIGHT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP OF REVENUE MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-288-5340
Mailing Address - Street 1:10888 S 300 W
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4043
Mailing Address - Country:US
Mailing Address - Phone:801-619-4900
Mailing Address - Fax:801-619-8077
Practice Address - Street 1:2111 W HISTORIC HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:801-619-4900
Practice Address - Fax:801-619-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM06-000007883416A0800X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI06023803Medicaid
CAXMTA05996Medicaid
NMRB48OtherBC'BS OF NM PROVIDER #
IA0551606Medicaid
800185OtherFEDERAL BLACK LUNG PROGRA
AZ804824Medicaid
NMG1735Medicaid
CO93272839Medicaid
NMG1735Medicaid
CAXMTA05996Medicaid