Provider Demographics
NPI:1730147430
Name:PARK CITY AMBULANCE SERVICE
Entity type:Organization
Organization Name:PARK CITY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-633-9898
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59063
Mailing Address - Country:US
Mailing Address - Phone:406-549-7104
Mailing Address - Fax:406-542-2785
Practice Address - Street 1:102 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:MT
Practice Address - Zip Code:59063
Practice Address - Country:US
Practice Address - Phone:406-633-2345
Practice Address - Fax:406-633-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1053416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0446511Medicaid
MT65102OtherBCBS
MT65102OtherBCBS
MT590006832Medicare ID - Type UnspecifiedRAILROAD MEDICARE