1861499139 NPI number — THREE RIVERS AMBULANCE AUTHORITY

Table of content: (NPI 1861499139)

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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