Basic Information
| Provider Information | |||||||||
| NPI: | 1437144284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADISON AMBULANCE ASSOCIATION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 195 ROUTE 80 | ||||||||
| Address2: | |||||||||
| City: | KILLINGWORTH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064191400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606633634 | ||||||||
| FaxNumber: | 8606633795 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 OLD ROUTE 79 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064432604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032459821 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 02/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | DEBURRA | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2032455617 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | N | Transportation Services | Ambulance | Land Transport | 3416L0300X | C076P1 | CT | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | CT0849 | 01 | HEALTHNET | OTHER | 590003585 | 01 | RAILROAD MEDICARE | OTHER | 004084406 | 05 | CT | MEDICAID | 710C076P1CT01 | 01 | BLUE CROSS/BLUE SHIELD | OTHER |