Basic Information
| Provider Information | |||||||||
| NPI: | 1497741466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHIPPENVILLE ELK TOWNSHIP VOLUNT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SHIPPENVILLE/ELK VOLUNTEER AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181050207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004732278 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 207 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SHIPPENVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162543905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147826245 | ||||||||
| FaxNumber: | 8147823327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JEANNERAT | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8147826245 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 03021 | PA | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 0012691900004 | 05 | PA | MEDICAID | 282131 | 01 | BCBS OF PA BLUE SHIELD | OTHER | 590010198 | 01 | UNITED HC RR MEDICARE | OTHER | 000000 | 01 | NY DPA COMPUTER SCIENCES | OTHER | 000000 | 01 | NY EMPIRE MEDICARE | OTHER | 081243600 | 01 | FEDERAL BLACK LUNG | OTHER |