Provider Demographics
NPI:1306896576
Name:FOUNTAIN AMBULANCE SERVICE INC
Entity type:Organization
Organization Name:FOUNTAIN AMBULANCE SERVICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-495-1220
Mailing Address - Street 1:PO BOX 198408
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5237 HALLS MILL RD
Practice Address - Street 2:BUILDING D
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36619-9603
Practice Address - Country:US
Practice Address - Phone:251-478-7200
Practice Address - Fax:251-478-3888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALAL0000D100169OtherSECTION 1011
AL20049104Medicaid
AL590011529OtherRAILROAD MEDICARE
AL50165FOUOtherBLUECROSS BLUESHIELD OF A
000050165Medicare PIN
AL590011529OtherRAILROAD MEDICARE