Basic Information
| Provider Information | |||||||||
| NPI: | 1124017637 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOONE COUNTY AMBULANCE AUTHORITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045227533 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 EMS CIRCLE | ||||||||
| Address2: | |||||||||
| City: | RACINE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048373911 | ||||||||
| FaxNumber: | 3048373913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 11/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045227533 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | WV | N | Transportation Services | Ambulance | 341600000X | WVEMS | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 001705393 | 01 | WV | BC | OTHER | 0145756000 | 05 | WV | MEDICAID | 590011860 | 01 | WV | RAILROAD MEDICARE | OTHER |