Provider Demographics
NPI:1124017637
Name:BOONE COUNTY AMBULANCE AUTHORITY
Entity Type:Organization
Organization Name:BOONE COUNTY AMBULANCE AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-522-7533
Mailing Address - Street 1:836 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701
Mailing Address - Country:US
Mailing Address - Phone:304-522-7533
Mailing Address - Fax:304-522-4222
Practice Address - Street 1:1 EMS CIRCLE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WV
Practice Address - Zip Code:25165
Practice Address - Country:US
Practice Address - Phone:304-837-3911
Practice Address - Fax:304-837-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV341600000X
WVWVEMS341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001705393OtherBC
WV0145756000Medicaid
WV590011860OtherRAILROAD MEDICARE
WV001705393OtherBC
WV590011860OtherRAILROAD MEDICARE
WV590011860Medicare PIN