1861499139 NPI number — THREE RIVERS AMBULANCE AUTHORITY

Table of content: JEFFREY SAMUEL CHEESMAN MD (NPI 1134652829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861499139 NPI number — THREE RIVERS AMBULANCE AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE RIVERS AMBULANCE AUTHORITY
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:
1861499139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11724
Provider Second Line Business Mailing Address:
525 HAYDEN ST
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46860-1724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-420-6500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 HAYDEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46802-3550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-420-6500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BENZ
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
260-420-6500

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  0114 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0114 . This is a "STATE EMS PROVIDER CERT" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100288230A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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