Basic Information
| Provider Information | |||||||||
| NPI: | 1336151315 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKE COUNTY COMMISSION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BROOKE COUNTY AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045211576 | ||||||||
| FaxNumber: | 3045211768 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 MARSHALL STREET | ||||||||
| Address2: | |||||||||
| City: | WELLSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047377094 | ||||||||
| FaxNumber: | 3047377251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOWLER | ||||||||
| AuthorizedOfficialFirstName: | K. ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3047377094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | WVEMS | WV | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | AMB302 | 01 | WV | UPPER OHIO VALLEY H PLAN | OTHER | 0145167000 | 05 | WV | MEDICAID | AMB302 | 01 | OH | UPPER OHIO VALLEY H PLAN | OTHER | 001705606 | 01 | WV | MT STATE BLUE CROSS | OTHER |