Basic Information
| Provider Information | |||||||||
| NPI: | 1215925763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELLENVILLE FIRST AID & RESCUE SQUAD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181050207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846642007 | ||||||||
| FaxNumber: | 4846642015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WEBSTER ST | ||||||||
| Address2: | |||||||||
| City: | ELLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124281109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456478181 | ||||||||
| FaxNumber: | 8456473947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | GRUNDT | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8456478181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 5515 | NY | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 01581800 | 05 | NY | MEDICAID |