Basic Information
| Provider Information | |||||||||
| NPI: | 1811196769 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WETZEL COUNTY EMERGENCY AMBULANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | WETZEL COUNTY EMERGENCY AMBULANCE AUTHORITY GRANDVIEW | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045227533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | RR 2 BOX 83 | ||||||||
| Address2: | |||||||||
| City: | PROCTOR | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260559716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044555931 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 05/13/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLVIN | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 3044555931 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | WV EMS | WV | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 001705439 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 0596814 | 05 | OH | MEDICAID | 081132300 | 01 | WV | BLACK LUNG | OTHER | 0145310000 | 05 | WV | MEDICAID | 590012566 | 01 | WV | RAILROAD MEDICARE | OTHER |