Provider Demographics
NPI:1194842781
Name:AETNA AMBULANCE SERVICE, INC
Entity Type:Organization
Organization Name:AETNA AMBULANCE SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-647-9798
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06045-1150
Mailing Address - Country:US
Mailing Address - Phone:860-240-7575
Mailing Address - Fax:860-643-0759
Practice Address - Street 1:140 VAN BLOCK AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2845
Practice Address - Country:US
Practice Address - Phone:860-247-6792
Practice Address - Fax:860-724-3384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTL064P23416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004072120Medicaid
CT004072120Medicaid