Basic Information
| Provider Information | |||||||||
| NPI: | 1780682773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONTGOMERY COUNTY AMBULANCE | ||||||||
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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: | 805 INDIAN MOUND DRIVE | ||||||||
| Address2: | |||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594981318 | ||||||||
| FaxNumber: | 8594983809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8594981318 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 1445 | KY | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 610988811 | 01 | KY | TRICARE | OTHER | 50005079 | 01 | KY | PASSPORT | OTHER | 200528290A | 05 | IN | MEDICAID | 2593297 | 05 | OH | MEDICAID | 55087043 | 05 | KY | MEDICAID | 56004435 | 05 | KY | MEDICAID | 590001325 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000070315 | 01 | KY | ANTHEM | OTHER | 606386600 | 01 | KY | BLACK LUNG | OTHER |