Basic Information
| Provider Information | |||||||||
| NPI: | 1831175660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOODWILL STEAM FIRE ENGINE CO - 1 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GOODWILL AMBULANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181050207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846642007 | ||||||||
| FaxNumber: | 4846642015 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109700878 | ||||||||
| FaxNumber: | 6109709263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOLLAR | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6109700878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 02259 | PA | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 0007316500001 | 05 | PA | MEDICAID |