Basic Information
| Provider Information | |||||||||
| NPI: | 1164420089 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUNTINGTON TOWNSHIP TRUSTEES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ABERDEEN HUNTINGTON TOWNSHIP VOL. LIFE SQUAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377950013 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 2164 STATE ROUTE 763 | ||||||||
| Address2: | |||||||||
| City: | ABERDEEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451019346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANG | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 9377950013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | OH | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 55000103 | 05 | KY | MEDICAID | 202066 | 05 | OH | MEDICAID | 000000494926 | 01 | OH | ANTHEM | OTHER |