Provider Demographics
NPI:1083899363
Name:MIDATLANTIC REGIONAL AMBULANCE INC
Entity Type:Organization
Organization Name:MIDATLANTIC REGIONAL AMBULANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-273-7360
Mailing Address - Street 1:P.O. BOX 896
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23705-0896
Mailing Address - Country:US
Mailing Address - Phone:757-273-7360
Mailing Address - Fax:757-273-7557
Practice Address - Street 1:549 PROGRESS LANE
Practice Address - Street 2:SUITE 106
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23454-3476
Practice Address - Country:US
Practice Address - Phone:757-273-7360
Practice Address - Fax:757-273-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
VA1282341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA190001998Medicare PIN