1568441814 NPI number — BEAVERDALE AREA AMBULANCE SERVICE, INC.

Table of content: (NPI 1568441814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568441814 NPI number — BEAVERDALE AREA AMBULANCE SERVICE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAVERDALE AREA AMBULANCE SERVICE, INC.
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:
Provider Other Organization Name Type Code:
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:
1568441814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 816
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15907-0816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-536-9951
Provider Business Mailing Address Fax Number:
814-536-9952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 CAMERON AVE
Provider Second Line Business Practice Location Address:
BOX 435
Provider Business Practice Location Address City Name:
BEAVERDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15921-0435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-487-5407
Provider Business Practice Location Address Fax Number:
814-487-5407
Provider Enumeration Date:
01/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVANCKIC
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
814-487-5407

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  1100379 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X , with the licence number: 06118 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0007322270002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000286911 . This is a "HIGHMARK BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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