Provider Demographics
NPI:1386773091
Name:SAMSON VOL. RESCUE SQUAD
Entity type:Organization
Organization Name:SAMSON VOL. RESCUE SQUAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAPTIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGINTON
Authorized Official - Suffix:
Authorized Official - Credentials:EMR
Authorized Official - Phone:334-898-2471
Mailing Address - Street 1:P O BOX 22
Mailing Address - Street 2:
Mailing Address - City:SAMSON
Mailing Address - State:AL
Mailing Address - Zip Code:36477
Mailing Address - Country:US
Mailing Address - Phone:334-898-1183
Mailing Address - Fax:334-898-1153
Practice Address - Street 1:9 S RIPLEY ST
Practice Address - Street 2:
Practice Address - City:SAMSON
Practice Address - State:AL
Practice Address - Zip Code:36477-1410
Practice Address - Country:US
Practice Address - Phone:334-898-1153
Practice Address - Fax:334-898-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4713416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000050191Medicaid
AL200031101Medicaid
AL000050191Medicare PIN