Basic Information
| Provider Information | |||||||||
| NPI: | 1285785105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLAYMONT FIRE COMPANY 1 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CLAYMONT FIRE COMPANY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 71 OMEGA DR BLDG D | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022833300 | ||||||||
| FaxNumber: | 3022833321 | ||||||||
| Practice Location | |||||||||
| Address1: | 3223 PHILADELPHIA PIKE | ||||||||
| Address2: | |||||||||
| City: | CLAYMONT | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197033101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027986858 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 3027986858 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NREMT-B | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 3737 | DE | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 0000537315 | 05 | DE | MEDICAID |