Basic Information
Provider Information | |||||||||
NPI: | 1174514913 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAIRFIELD VOL FIRE CO NO1 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAIRTON FIRE CO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 66 | ||||||||
Address2: |   | ||||||||
City: | BRIDGETON | ||||||||
State: | NJ | ||||||||
PostalCode: | 083200066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004732278 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 43 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | NJ | ||||||||
PostalCode: | 08320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8564513676 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2005 | ||||||||
LastUpdateDate: | 04/16/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BATEMAN | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
AuthorizedOfficialTelephone: | 8564513676 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X |   |   | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 1079100 | 01 |   | KEYSTONE MERCY HMO DPA | OTHER | 240357 | 01 |   | NJ MEDICARE HGSA | OTHER | 0959952 | 01 |   | AETNA USHC BLUE BELL HMO | OTHER | 0X00PA7334 | 01 |   | QUALMED | OTHER | 0X00PA7334 | 01 |   | ACS HEALTH NET HMO MDC | OTHER | 0X00PA7334 | 01 |   | PHS HEALTH PLAN COMMERCIA | OTHER | 0000240357 | 01 |   | MEDICARE HGSA | OTHER | 0X00PA7334 | 01 |   | PHS HEALTH PLAN HMO MDC | OTHER | 7566301 | 01 |   | UNYSIS NJ MEDICAID | OTHER | 0X00PA7334 | 01 |   | ACS HEALTH NET COMMERCIAL | OTHER |