Basic Information
| Provider Information | |||||||||
| NPI: | 1801892013 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLEN DALE VOL. FIRE DEPT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045227533 | ||||||||
| FaxNumber: | 3045224222 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 WHEELING AVE. | ||||||||
| Address2: | |||||||||
| City: | GLEN DALE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048458800 | ||||||||
| FaxNumber: | 3048453475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | PASTORIUS | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 3048458800 | ||||||||
| 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 | 590013702 | 01 | WV | RAILROAD MEDICARE | OTHER | 0144885000 | 05 | WV | MEDICAID |