Basic Information
| Provider Information | |||||||||
| NPI: | 1619963782 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OTTO TOWNSHIP VOLUNTEER FIRE DEPARTMENT & AMBULANCE ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181050207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004732278 | ||||||||
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| Practice Location | |||||||||
| Address1: | 118 SWEITZER DR | ||||||||
| Address2: | |||||||||
| City: | DUKE CENTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167299506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149663311 | ||||||||
| FaxNumber: | 8149663311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 01/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | RETTGER | ||||||||
| AuthorizedOfficialFirstName: | JOSH | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASST CAPTAIN | ||||||||
| AuthorizedOfficialTelephone: | 8145985822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 04306 | PA | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 0011940250005 | 05 | PA | MEDICAID | 213777 | 01 | PA | BCBS | OTHER |