Basic Information
| Provider Information | |||||||||
| NPI: | 1689660797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY OF PERTH AMBOY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 WASHINGTON ST | ||||||||
| Address2: | C/O DCM INC | ||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087536855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322403030 | ||||||||
| FaxNumber: | 7329140470 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | PERTH AMBOY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088614451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328260290 | ||||||||
| FaxNumber: | 7329140470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | PERLEE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | BA | ||||||||
| AuthorizedOfficialTelephone: | 7328260290 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | N/A | NJ | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | P00347146 | 01 | NJ | RAILROAD MEDICARE | OTHER | 0071013 | 05 | NJ | MEDICAID |