1407018823 NPI number — EMSSTAR LLC

Table of content: (NPI 1407018823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407018823 NPI number — EMSSTAR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMSSTAR LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EM-STAR AMBULANCE SERVICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407018823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 DOMINO LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19128-4352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-764-8803
Provider Business Mailing Address Fax Number:
215-827-5608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 N GRAHAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18109-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-764-8803
Provider Business Practice Location Address Fax Number:
215-827-5608
Provider Enumeration Date:
06/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOLLENDORF
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-764-8803

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  04228 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3416L0300X , with the licence number: EMST22015 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X , with the licence number: EMST22015 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0077488 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1011955800001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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