Basic Information
| Provider Information | |||||||||
| NPI: | 1528066511 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MASON COUNTY EMERGENCY AMBULANCE SERVICE AUTHORITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006764785 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 EMERGENCY DRIVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255502005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046756134 | ||||||||
| FaxNumber: | 3046757433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | CHUCK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 3046756134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | WV EMS | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 080025800 | 01 | WV | BLACK LUNG | OTHER | 590013584 | 01 | WV | RAILROAD MEDICARE | OTHER | 001705580 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 2196556 | 05 | OH | MEDICAID | 9000056000 | 05 | WV | MEDICAID |