Basic Information
| Provider Information | |||||||||
| NPI: | 1578559555 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KULPMONT COMMUNITY AMB ASSOC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 207 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181050207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004732278 | ||||||||
| FaxNumber: | 4846642017 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 N 8TH ST | ||||||||
| Address2: | |||||||||
| City: | KULPMONT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178341343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703731103 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OHEARN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5703731103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | EMT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 811890 | 01 | FIRST PRIORITY HEALTH | OTHER | 0012017920004 | 01 | PA MEDICAID | OTHER | 0820315 | 01 | AETNA USHC BLUE BELL HMO | OTHER | 214022 | 01 | BC BS OF PA BLUE SHIELD | OTHER | 804534 | 01 | UMWA HEALTH & RETIREMENT | OTHER |