Basic Information
| Provider Information | |||||||||
| NPI: | 1720200991 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETERSTOWN VOLUNTEER FIRE DEPARTMENT AND RESCUE SQUAD INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PETERSTOWN VOLUNTEER FIRE AND RESCUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045211576 | ||||||||
| FaxNumber: | 3045211768 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | PETERSTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047534343 | ||||||||
| FaxNumber: | 3047539537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHEELER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045211576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | N | Transportation Services | Ambulance | 341600000X | WVEMS | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 001705363 | 01 | WV | BC/BS | OTHER | 0145724000 | 05 | WV | MEDICAID | 001705363 | 01 | WV | MT. STATE BLUE CROSS | OTHER |