Provider Demographics
NPI:1134131949
Name:STARK COUNTY AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:STARK COUNTY AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:ROESNER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:309-286-7154
Mailing Address - Street 1:114 NORTH FRANKLIN STREET POB 236
Mailing Address - Street 2:
Mailing Address - City:TOULON
Mailing Address - State:IL
Mailing Address - Zip Code:61483-0236
Mailing Address - Country:US
Mailing Address - Phone:309-286-7154
Mailing Address - Fax:309-286-0028
Practice Address - Street 1:114 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:TOULON
Practice Address - State:IL
Practice Address - Zip Code:61483
Practice Address - Country:US
Practice Address - Phone:309-286-7154
Practice Address - Fax:309-286-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2574341600000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00047628OtherRAILROAD MEDICARE CARRIER
IL=========001Medicaid
IL541890Medicare ID - Type Unspecified