Provider Demographics
NPI:1205863453
Name:EASTERN SHORE AMBULANCE INC
Entity Type:Organization
Organization Name:EASTERN SHORE AMBULANCE INC
Other - Org Name:EASTERN SHORE AMBULANCE SERVICE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AR MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-343-7153
Mailing Address - Street 1:PO BOX 538194
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8194
Mailing Address - Country:US
Mailing Address - Phone:866-343-7153
Mailing Address - Fax:757-787-9436
Practice Address - Street 1:3301 AIRLINE BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2661
Practice Address - Country:US
Practice Address - Phone:866-343-7153
Practice Address - Fax:757-787-9436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5353416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9002472Medicaid
VA098503OtherANTHEM BCBS PROVIDER NUMB
VA13616OtherVETRI PROVIDER NUMBER
VA590012982OtherRAILROAD MEDICARE
VA590012982Medicare PIN
VA098503OtherANTHEM BCBS PROVIDER NUMB