Provider Demographics
NPI:1063442739
Name:BOONSBORO AMBULANCE AND RESCUE SERVICE INCORPORATED
Entity Type:Organization
Organization Name:BOONSBORO AMBULANCE AND RESCUE SERVICE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLICKENSTAFF
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:301-432-6979
Mailing Address - Street 1:7619 OLD NATIONAL PIKE
Mailing Address - Street 2:PO BOX 7
Mailing Address - City:BOONSBORO
Mailing Address - State:MD
Mailing Address - Zip Code:21713-2003
Mailing Address - Country:US
Mailing Address - Phone:301-432-6979
Mailing Address - Fax:301-432-2265
Practice Address - Street 1:7619 OLD NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:BOONSBORO
Practice Address - State:MD
Practice Address - Zip Code:21713-2003
Practice Address - Country:US
Practice Address - Phone:301-432-6979
Practice Address - Fax:301-432-2265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD310778043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD466518000Medicaid
MDS1980001OtherFEDERAL BLUE CROSS
MDDM13OtherBLUE CROSS BLUE SHIELD
MDS1980001OtherFEDERAL BLUE CROSS
MD466518000Medicaid