This study uses a survey of all ground-based prehospital emergency medical services (EMS) agencies in nine states (AR, FL, KS, MA, MT, NM, OR, SC, WI) to examine supply and demand for emergency response personnel, the involvement of medical directors, and the availability of medical consultation, in rural and urban agencies. Compared with urban EMS agencies, rural agencies had lower staff skill levels, higher reliance on volunteers, higher vacancy ratios, and less access to oversight and skill maintenance through regular interaction with a medical director and online medical consultation during emergency calls. Agencies in isolated small rural areas were the most distinct from other rural and urban agencies, having the most volunteers (both EMS providers and medical directors) and paid staff vacancies.