Provider Demographics
NPI:1699769158
Name:PUCKETT EMERGENCY MEDICAL SERVICES, LLC
Entity type:Organization
Organization Name:PUCKETT EMERGENCY MEDICAL SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF REVENUE INTEGRATION OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-597-4911
Mailing Address - Street 1:PO BOX 650523
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0523
Mailing Address - Country:US
Mailing Address - Phone:844-597-4911
Mailing Address - Fax:866-687-2796
Practice Address - Street 1:3760 TRAMORE POINT PKWY
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-222-5045
Practice Address - Fax:770-943-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA03343341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000902107AMedicaid
GA59RCBLLMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
GA000902107AMedicaid