Basic Information
| Provider Information | |||||||||
| NPI: | 1205803004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINTERPORT FIRE AND RESCUE ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINTERPORT VOLUNTEER AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 724 | ||||||||
| Address2: | |||||||||
| City: | WINTERPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044960724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075549990 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WINTERPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044963225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075549990 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | LOGAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2075057965 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 41512 | 01 | BLUE CROSS | OTHER | 112620000 | 05 | ME | MEDICAID |