Basic Information
| Provider Information | |||||||||
| NPI: | 1083613418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHGATE VOLUNTEER FIRE DEPARTMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 ELECTRIC AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410713166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594411422 | ||||||||
| FaxNumber: | 8597815598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8594411422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 1539 | KY | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 61607801500 | 01 | WV | WV WORKERS COMP | OTHER | 590009391 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000340543 | 01 | KY | ANTHEM | OTHER | 55001093 | 05 | KY | MEDICAID |