Provider Demographics
NPI:1013180934
Name:CONWAY-SEVERN RESCUE SQUAD INC
Entity Type:Organization
Organization Name:CONWAY-SEVERN RESCUE SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-452-8191
Mailing Address - Street 1:PO BOX 290184
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06129-0184
Mailing Address - Country:US
Mailing Address - Phone:800-452-8191
Mailing Address - Fax:
Practice Address - Street 1:113 WHITE STREET
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NC
Practice Address - Zip Code:27820
Practice Address - Country:US
Practice Address - Phone:252-585-0026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1256341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1013180934Medicaid
NC3406979Medicaid
VA1013180934Medicaid