Basic Information
| Provider Information | |||||||||
| NPI: | 1497720072 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELKHORN AMBULANCE SERVICE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
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| Practice Location | |||||||||
| Address1: | 223 BRIDGE STREET | ||||||||
| Address2: | |||||||||
| City: | ELKHORN CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067545173 | ||||||||
| FaxNumber: | 6067545813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 6067545173 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 1658 | KY | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 50008744 | 01 | KY | PASSPORT | OTHER | 56028855 | 05 | KY | MEDICAID | 2623138 | 05 | OH | MEDICAID | 000000389814 | 01 | KY | ANTHEM | OTHER | 010223474 | 05 | VA | MEDICAID | 406590993 | 01 | KY | RR MEDICARE | OTHER | 1069699 | 01 | WV | WV WORKERS COMP | OTHER | 55001234 | 05 | KY | MEDICAID | 610830100 | 01 | KY | BLACK LUNG | OTHER |