Active NPI
County of Pulaski
- Land Ambulance
- Mounds, IL
National Provider Identifier
1043319148
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Land Ambulance
- Legal business name
- COUNTY OF PULASKI
- Practice address
- 75 Camo Clad Dr
Pulaski County Ambulance
Mounds, IL 62964 - Phone
- (618) 342-6209
- Fax
- (618) 342-6254
- NPI assigned
- Sep 22, 2006
- Last updated
- Aug 11, 2022
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Tracie Dawn Hafford
- Title
- Director
- Phone
- (314) 677-0185
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ambulance | 341600000X | |||
| Land Ambulance | 3416L0300X | Primary |
Addresses
Primary practice location
75 Camo Clad Dr
Pulaski County Ambulance
Mounds, IL 62964
Mailing address
PO Box 52
Mounds, IL 62964-0052
Phone (618) 342-6209
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 07770390 | Other | IL | BLUE CROSS BLUE SHIELD |
| 371076724001 | Medicaid | IL | |
| 590000202 | Other | IL | RAIL ROAD MEDICARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040102000441 | IL | Part B Supplier - Ambulance Service Supplier | 1951200542 | Practice locations: Mounds, IL |
National Provider Directory
National Provider DirectoryLocations
75 Camo Clad Dr
Mounds, IL 62964
Phone (618) 342-6209
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158883200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1660176000000",
"number": "1043319148",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 52",
"city": "MOUNDS",
"state": "IL",
"postal_code": "629640052",
"telephone_number": "618-342-6209",
"fax_number": "618-342-6254"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "75 CAMO CLAD DR",
"address_2": "PULASKI COUNTY AMBULANCE",
"city": "MOUNDS",
"state": "IL",
"postal_code": "62964",
"telephone_number": "618-342-6209",
"fax_number": "618-342-6254"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "COUNTY OF PULASKI",
"organizational_subpart": "NO",
"enumeration_date": "2006-09-22",
"last_updated": "2022-08-11",
"certification_date": "2022-08-11",
"status": "A",
"authorized_official_last_name": "HAFFORD",
"authorized_official_first_name": "TRACIE",
"authorized_official_middle_name": "DAWN",
"authorized_official_title_or_position": "DIRECTOR",
"authorized_official_telephone_number": "314-677-0185"
},
"taxonomies": [
{
"code": "341600000X",
"taxonomy_group": "",
"desc": "Ambulance",
"state": null,
"license": null,
"primary": false
},
{
"code": "3416L0300X",
"taxonomy_group": "",
"desc": "Ambulance, Land Transport",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "07770390",
"state": "IL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "371076724001",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAIL ROAD MEDICARE",
"identifier": "590000202",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Mounds, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 11, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.