Provider Demographics
NPI:1114079688
Name:SPEEDWAY
Entity Type:Organization
Organization Name:SPEEDWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:KATSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:AMBULETTE
Authorized Official - Phone:216-355-8011
Mailing Address - Street 1:27645 BISHOP PARK DR #508
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2763
Mailing Address - Country:US
Mailing Address - Phone:216-355-8011
Mailing Address - Fax:440-347-9939
Practice Address - Street 1:27645 BISHOP PARK DR #508
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-2763
Practice Address - Country:US
Practice Address - Phone:216-355-8011
Practice Address - Fax:440-347-9939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH435075343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2659234Medicaid