Orange County NC Website
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />DEPARTMENT OF HEALTH SERVICE REGULATION <br />OFFICE OF EMERGENCY MEDICAL SERVICES <br /> 1201 Umstead Drive | 2707 Mail Service Center | Raleigh, NC 27603-2008 | Phone: (919) 855-3935 | Fax: (919) 733-7021 <br /> <br /> <br />EMD CENTER RENEWA L A PPL ICA TION <br />Effective: 8/1/2014 <br /> <br />This application is for renewal of Emergency Medical Dispatch (EMD) Centers. EMD Centers must be operational twenty-four (24) hours a day, seven (7) days a <br />week. Each highlighted section must be completed. Information in the Credentialing Information System (CIS) must be current prior to application submission. <br />Endorsements from the EMD Center Director, EMS System Administrator, System Medical Director, and County Manager (if applicable) are required. Renewals <br />must be submitted to the appropriate regional EMS office indicated below. <br />GENERAL INFORMATION <br />EMD Center Name: Office Number: <br />Physical Address: Fax Number: <br />City: State:Provider Admin Contact: <br />County: Zip:Title: <br />Mailing Address: Office Number: <br />City: State:MobileNumber: <br />County: Zip:FaxNumber: <br />PROVIDER PROPERTIES E-mail Address: <br />Provider Number: System Affiliation: <br />Renewals must be submitted to the appropriate regional office indicated below: <br />CENTRAL <br />Central Regional Office of EMS <br />801 Biggs Drive <br />2717 Mail Service Center <br />Raleigh, NC 27699-2717 <br />Office: (919) 855-4678 <br />Fax: (919) 715-0498 <br />EASTERN <br />Eastern Regional Office of EMS <br />404 St. Andrews Drive, Suite 7 <br />Greenville, NC 27834-6850 <br />Office: (252) 355-9026 <br />Fax: (2525) 355-9063 <br />WESTERN <br />Western Regional Office of EMS <br />3305 16th Avenue SE, Suite 302 <br />Conover, NC 28613-9213 <br />Office: (828) 466-5548 <br />Fax: (828) 466-5651 <br />BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST <br />EMD Center Renewal Effective 8/1/2014 <br />DHHS/DHSR/OEMS 4917 <br />Page 1 of 3 <br />DocuSign Envelope ID: 0123867B-484A-40EF-9EC6-2607BAF583F8 <br />0680960 <br />919 245-6139 <br />919 245-6100 <br />kmedlin@orangecountync.gov <br />27278 <br />919 732-8130 <br />Interim 9-1-1 Operations Manager <br />919 732-5016 <br />Hillsborough <br />Orange County Emergency Services <br />Orange <br />Orange County <br />PO Box 8181 <br />NCKevin Medlin <br />500 Meadowlands Drive <br />Hillsborough <br />NC <br />Orange <br />NC