Basic Information
| Provider Information | |||||||||
| NPI: | 1952478737 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOWN OF MADAWASKA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MADAWASKA AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1820 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047691820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077647529 | ||||||||
| FaxNumber: | 2077646504 | ||||||||
| Practice Location | |||||||||
| Address1: | 428 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MADAWASKA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047561105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077286126 | ||||||||
| FaxNumber: | 2077283618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PICARD | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | TOWN MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2077286351 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | 437 | ME | N | 193400000X SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic | 341600000X | N | Transportation Services | Ambulance | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 007776 | 01 | ME | ANTHEM PROVIDER ID | OTHER | 136820000 | 05 | ME | MEDICAID |