Provider Demographics
NPI:1023179132
Name:ICKESBURG AMBULANCE ASSOCIATION
Entity Type:Organization
Organization Name:ICKESBURG AMBULANCE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-438-0384
Mailing Address - Street 1:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:ICKESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17037-0163
Mailing Address - Country:US
Mailing Address - Phone:717-438-3113
Mailing Address - Fax:
Practice Address - Street 1:10350 RACCOON VALLEY RD
Practice Address - Street 2:
Practice Address - City:ICKESBURG
Practice Address - State:PA
Practice Address - Zip Code:17037
Practice Address - Country:US
Practice Address - Phone:717-438-3113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA04274146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001437455Medicaid
PA001437455Medicaid