1861577991 NPI number — LOGAN COUNTY EMERGENCY AMBULANCE SERVICE

Table of content: (NPI 1861577991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861577991 NPI number — LOGAN COUNTY EMERGENCY AMBULANCE SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGAN COUNTY EMERGENCY AMBULANCE SERVICE
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:
6
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:
1861577991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 DINGESS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25601-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-752-0917
Provider Business Mailing Address Fax Number:
304-752-7661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 DINGESS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-752-0917
Provider Business Practice Location Address Fax Number:
304-752-7661
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRYANT
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
ELMO
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
304-752-0917

Provider Taxonomy Codes

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

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

  • Identifier: 0145690000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59000469 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001705385 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 086191300 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 72447ML1 . This is a "MAMSI" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1270523 . This is a "UMWA HEALTH & RET. FUND" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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