Provider Demographics
NPI:1679561864
Name:POLK COUNTY EMERGENCY MEDICAL SERVICE
Entity type:Organization
Organization Name:POLK COUNTY EMERGENCY MEDICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-748-7848
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-0268
Mailing Address - Country:US
Mailing Address - Phone:770-748-7848
Mailing Address - Fax:770-749-1050
Practice Address - Street 1:1700 ROCKMART HWY
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-6021
Practice Address - Country:US
Practice Address - Phone:770-748-7848
Practice Address - Fax:770-749-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA115-03341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA105654Medicaid
GA105654Medicaid