Basic Information
| Provider Information | |||||||||
| NPI: | 1023048261 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KILLINGWORTH AMBULANCE ASSOCIATION, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 195 ROUTE 80 | ||||||||
| Address2: | |||||||||
| City: | KILLINGWORTH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064191400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606633634 | ||||||||
| FaxNumber: | 8606633795 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 ROUTE 81 | ||||||||
| Address2: | |||||||||
| City: | KILLINGWORTH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064199999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606633634 | ||||||||
| FaxNumber: | 8606633795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 05/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | O'SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8606632450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | E5415 | CT | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 699842 | 01 | CT | CONNECTICARE | OTHER | 590014003 | 01 | CT | RAILROAD MEDICARE | OTHER | 004010492 | 05 | CT | MEDICAID | 710C070A2CT01 | 01 | CT | ANTHEM BLUE CROSS | OTHER | CT2195 | 01 | CT | HEALTHNET | OTHER |