Provider Demographics
NPI:1962583575
Name:CITY OF GUYMON
Entity type:Organization
Organization Name:CITY OF GUYMON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:WADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-338-5537
Mailing Address - Street 1:219 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-4708
Mailing Address - Country:US
Mailing Address - Phone:800-538-8278
Mailing Address - Fax:580-628-2273
Practice Address - Street 1:219 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-4708
Practice Address - Country:US
Practice Address - Phone:800-538-8278
Practice Address - Fax:580-628-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS1733416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100819780AMedicaid
OK=========001OtherBCBS PROVIDER
OK=========001OtherBCBS PROVIDER
=========Medicare PIN